Guide To Assessment Scales in Major Depressive Disorder

George Alexopoulos · Siegfried Kasper
Hans-Jürgen Möller · Carmen Moreno
Guide to
Assessment Scales
in Major Depressive
Disorder
George Alexopoulos
Siegfried Kasper
Hans-Jürgen Möller
Carmen Moreno
Guide to
Assessment Scales
in Major Depressive
Disorder
George Alexopoulos
Cornell University, New York, USA
Siegfried Kasper
Medical University of Vienna, Austria
Ludwig Maximilian University, Munich, Germany
Carmen Moreno
Complutense University, Madrid, Spain
Guide to
Assessment Scales
in Major Depressive
Disorder
Contributors
Marta Bravo, Maria Mayoral, Alejandra Teresa Laorden
ISBN 978-3-319-04626-6/ISBN (eBook) 978-3-319-04627-3
DOI 10.1007/978-3-319-04627-3
Springer Cham Heidelberg New York Dordrecht London
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Contents
Author biographies VII
1 Introduction to assessment in depression 1

Introduction 1
Multivariate analysis 1
Limitations of rating scales 2
Using assessment scales in clinical practice 3
References 4
2 Observer rating scales 7

Introduction 7
General aspects of observer rating scales 7
Examples of observer rating scales for depression 9
Featured scale: Hamilton Rating Scale for Depression 10
Featured scale: Montgomery-Åsberg Depression Rating Scale 16
References 18
3 Self-rating scales 23
General aspects of self-rating scales 23
Symptom assessment 24
Examples of self-rating scales in depression 27
Featured Scale: Beck Depression Inventory 30
References 31
4 Assessment of pediatric depression 35

General aspects of pediatric depression scales 35
Examples of scales in pediatric depression 36
Featured scale: Children’s Depression Inventory 39
References 40
5 Assessment scales for geriatric patients 43

General aspects of depression scales for geriatric patients 43
Symptom assessment 43
Example s of observer rating scales for geriatric patients 44
Featured scale: Cornell Scale for Depression in Dementia 47
References 49
Appendices A–D 53
Author biographies
George Alexopoulos, MD, is SP Tobin and AM Cooper Professor of Psychiatry, founder and
director of the Weill-Cornell Institute of Geriatric Psychiatry, and director of the Advanced
Center for Interventions and Services Research in Geriatric Mood Disorders at Cornell
University, New York, USA. Dr Alexopoulos received his MD from the National University
of Athens, Greece, trained at New Jersey Medical School, and completed his psychiatric
residency at Cornell University Medical College, where he completed a research fellowship
in Psychobiology. Dr Alexopoulos has made fundamental contributions to the study of
the biology of late-life depression including identifying brain mechanisms contributing
to poor response to antidepressant drugs, development of new treatments for patients
with depression and severe medical illnesses, and improving the practice model for the
identification and treatment of depression in primary care. Dr Alexopoulos has served on
the Board of Scientific Counselors of the National Institute of Mental Health and has received
four consecutive Center Grant Awards from the National Institute of Mental Health and
numerous individual grants. He has been the Director of the T32 NIMH Research Fellowship
in Geriatric Mood Disorders since 1989. Dr Alexopoulos is a fellow of the American College of
Neuropsychopharmacology, American College of Psychiatrists (ACP), and a Distinguished
Life Fellow of the American Psychiatric Association (APA). He has received several awards,
including an APA Presidential Commendation, the Research Award of the International
College of American College of Geriatric Psychoneuropharmacology, the APA Greenberg
Award, the ACP Geriatric Research Award, the Joseph Zubin Research Award of the American
Psychopathological Association, the APA Distinguished Psychiatrist Lecturer Award, and the
Senior Investigator’s Award of the American Association for Geriatric Psychiatry. Dr Alexopoulos
is the editor of the International Journal of Geriatric Psychiatry (Western Hemisphere) and has
published more than 400 articles and book chapters.
Siegfried Kasper, MD is Professor of Psychiatry and Chairman of the Department of Psychiatry

and Psychotherapy at the Medical University of Vienna, Austria. Dr Kasper serves/served on
the executive committees and advisory boards of several national and international societies,
such as the European College of Neuropsychopharmacology (ECNP) and the European
Psychiatric Association (EPA). He has been elected to the Executive Committee of the
International College of Neuropsychopharmacology (CINP) for the period of 2012 to 2016. He
is Chair of the World Psychiatric Association (WPA) Section of Pharmacopsychiatry, President
of the Austrian Society of Drug Safety in Psychiatry (ÖAMSP), and Past-President of the Austrian
Society of Neuropsychopharmacology and Biological Psychiatry (ÖGPB). Dr Kasper is an
Honorary Member of the Czech and Romanian Societies of Neuropsychopharmacology, the
Hungarian Psychiatric Association, and a Fellow of the Royal College of Psychiatrists (UK) and
Ukrainian Association of Psychiatry. Dr Kasper has been President of the 10th ECNP Congress
, Chairman of the Local Organizing Committee of the WPA Thematic Conference, and Co-
viii Auth o r B i o gra phies
Chair of the Local Organizing Committee of the WFSBP Congress. In 2009, he was President of
the WFSBP Congress in Paris. In 2005, he was appointed Honorary Professor at the University
of Hong Kong, China. From 2005 to 2009, Dr Kasper was President of the World Federation of
Societies of Biological Psychiatry (WFSBP) and was appointed as Honorary President of the
WFSBP in 2013. Dr Kasper serves on editorial boards of numerous learned journals, including
Lancet Psychiatry, Journal of Clinical Psychiatry, CNS Spectrums, Journal of Affective Disorders,
Pharmacopsychiatry, European Archives of Psychiatry, and Neuroscience. He is Editor-in-Chief of
the World Journal of Biological Psychiatry and the International Journal of Psychiatry in Clinical
Practice, and Field Editor of the International Journal of Neuropsychopharmacology. Dr Kasper has
published over 1000 ISI-listed publications and more than 200 book chapters.
Hans-Jürgen Möller, MD, is Emeritus Professor at the Department of Psychiatry, Ludwig

Maximilian University, Munich, Germany, where he was Chairman and Professor of Psychiatry
from 1994 to 2012. He has worked in the field of psychiatry for more than 40 years. After
obtaining his Doctor of Medical Science in 1972, he completed postgraduate training
in psychiatry at the Max Planck Institute of Psychiatry in Munich. From 1980 to 1988 he was
Professor of Psychiatry at Munich Technical University and from 1988 to 1994 full Professor
of Psychiatry and Chairman of the Department of Psychiatry at the University of Bonn. His
main scientific contributions include clinical and neurobiological research into psychiatry,
schizophrenia and depression and clinical psychopharmacology. He has written and co-
authored over 1,100 publications, including numerous original articles (Hirsch Factor 68)
and several books. He is co-editor of European Archives of Psychiatry and Clinical Neuroscience
and Psychopharmakotherapie, founding editor and former chief editor of The World Journal
of Biological Psychiatry and holds positions on the editorial boards of several national and
international psychiatric journals. He has been a member of the executive committees of many
national and international psychiatric societies. He was President of the World Federation of
Societies of Biological Psychiatry (WFSBP), President of the European Psychiatric Association
(EPA) and Chairman of the World Psychiatric Association (WPA) Section on Pharmacopsychiatry.
Currently, he is Past-President of the Collegium Internationale Neuro-Psychopharmacologicum
(CINP). He has received numerous awards including the WPA Jean Delay Prize and the WFSBP
Lifetime Achievement Award.
Carmen Moreno, MD, PhD, is a Child Psychiatrist and Associate Professor of the Gregorio
Marañón Psychiatry Department, Complutense University School of Medicine, Madrid, Spain.
Dr. Moreno completed her MD and PhD degrees at Autónoma University and Complutense
University in Madrid, and a Research Fellowship in Child and Adolescent Psychiatry at
Columbia University, New York, USA. Dr. Moreno has focused her career on early-onset
psychiatric disorders, mainly affective and psychotic disorders, and recently, also other
neurodevelopmental disorders. She is recognized by her studies in raising awareness of
Auth o r B i o gra phies ix
the misdiagnosis of bipolar disorder in children and adolescents. She has authored more
than 30 peer-reviewed publications. Her efforts are now focused on understanding the
role of inflammation and oxidative stress on early-onset psychiatric disorders, and towards
development of new treatment interventions.
1. Introduction to assessment in
depression
Siegfried Kasper, Hans-Jürgen Möller
Introduction
The diagnosis of depression has been revised over the past decade in accordance with the
International Statistical Classification (ICD-10) and Diagnostic and Statistical Manual of Mental
Disorders (DSM)-5 diagnostic criteria [1,2]. While these publications give a framework for the
classification of mental disorders, there is also a necessity for a multidimensional approach,
which can be obtained by using assessment scales for syndromes across different psychiatric
categories. It is worth noting that these scales cannot be used for establishing diagnosis but
are helpful for grading the severity of the condition irrespective of the diagnostic category, as
well as enabling treatment plans for psychopharmacological and psychotherapeutic methods.
Different psychometric rating scales have been used for evaluating psychotropic agents
within and across diagnostic categories. Although this indicates the validity of the scales used,
it does not mean that they are necessarily the most sensitive scales for certain indications.
One example is the Hamilton Depression Rating Scale for Depression (HAM-D), which can
overemphasize sedative antidepressants because there are three items for sleep disturbances
(in contrast to the Montgomery-Åsberg Rating Scale for Depression [MADRS] with only one
item relating to sleep parameters) [3,4]. It should be emphasized that many rating scales do
not adequately reflect our current understanding of the phenomenology of the disorders
(eg, male depression with higher levels of aggression), which may change as continued
research leads to the discovery of new neurobiological entities.
Multivariate analysis
Multivariate statistical analysis (factor and cluster analysis) of the data obtained from rating
scales may be used to derive factors. These factors identify groups of individual symptoms
that tend to occur together. If we consider that the term ‘clinical syndrome’ generally refers
to a group of symptoms that frequently occur in combination, it becomes apparent that the
Ó Springer International Publishing Switzerland 2014 1
G. Alexopoulos et al., Guide to Assessment Scales in Major Depressive Disorder,
DOI 10.1007/978-3-319-04627-3_1
2 Guide to A ssessment S cales in M aj o r D epressive D is o rder
factors extracted from rating scales relating to mental state are conceptually identical to clinical
syndromes. Multivariate analysis of the data obtained by using different multidimensional
psychiatric rating scales in different samples of patients has tended to repeatedly generate the
same factors or symptom clusters [5–10]:
•• paranoid hallucinatory syndrome;
•• manic syndrome;
•• depressive syndrome;
•• apathetic syndrome;
•• hypochondriac syndrome;
•• phobic-obsessive syndrome; and
•• amnesiac syndrome.
The factor structure of some well-developed observer rated scales has also been shown
to remain relatively stable across different studies and, for many of the factors, even across
repeated measurements over the course of treatment [11–13]. This invariability in the structure
of factors across different samples and time points is an important aspect of the validity of a
scale (factorial validity).
Limitations of rating scales

It is important to bear in mind that the items included in factors or dimensions may vary greatly
between scales, even if the names of the factors or dimensions are the same. Also, the correlation
might differ quite considerably between the scores of analogous factors or dimensions of a scale
and the total scores of two scales focusing on the same clinical phenomenon (eg, depression).
Possible consequences include discrepancies such as efficacy results in antidepressants trials;
for example, in a study on lamotrigine in bipolar depression, only the MADRS ratings showed a
statistically significant difference between lamotrigine and placebo, while the HAM-D ratings,
which were defined as the primary outcome measure, did not [14]. Therefore, careful thought must
be put into the selection of a scale for a clinical study.
The development of standardized rating scales, both observer and self-rating, is a time-
consuming, long-lasting process that includes several complex procedures to determine
validity and reliability, among other aspects [15]. This is one of the main reasons that only a
few psychometrically well-validated scales are widely available. However, the increasingly
popular trend to generate and publish new rating scales, eg, in the context of certain research
projects and often after a short development period, is not a recommended approach to for
advancing the field. For example, a scale cannot be designed by simply taking the DSM-5
or ICD-10 symptoms of depression, providing a scoring rubric, investigating a sample of
depressed patients, and then calculating the correlations between the total scores of the new
and the established scales. When assessing correlations with another scale, for example, it is
very important that the scale is evaluated in a sample of patients at all levels of severity (mild,
moderate, and severe). This is especially important if the new scale is a self-rating scale that is
I ntr o ducti o n to assessment in depressi o n 3
to be validated through its correlation with an observer rating scale, because the correlation
depends on severity. Such comparisons of self-rating and observer rating scales should also
include correlations over time because cross-sectional correlations can vary at different points
in time.
Nevertheless, such unprofessionally developed instruments sometimes attract
attention for a while, until the deficiencies, such as lack of validity or reliability, become clear.
Interestingly, psychometrically well-developed standardized rating instruments, including
the WHO instruments for the assessment of depressive disorders [16], sometimes do not gain
acceptance even when they have been carefully tested internationally; the reasons for this
phenomenon are unclear.
Thus, the development of new rating scales for psychopharmacological research is often
hampered because measures of efficacy using established scales are required by international
regulatory agencies to approve a new medication; outcome data from a new rating instrument
are regarded as supplemental evidence. Another problematic point is the possible overlap
between treatment-emergent side effects of psychoactive drugs with symptoms of psychiatric
disorders, which can only be disentangled by sound knowledge of both the disease as well as
the pharmacodynamic and pharmacokinetic properties of the compounds under evaluation.
Using assessment scales in clinical practice

Despite these limitations, it is evident that the available scales for depression, which are now
part of a standardized approach for assessment of most major mental disorder conditions,
are helpful for communication between patients and clinicians and aid in the evaluation of
treatment efficacy, from both an individual and statistical approach. Available scales can be
categorized as observer- or self-rating scales and it is evident that both approaches are needed
in order to obtain detailed information about the patient and the treatment process. In Chapter
2, these approaches are described along with the most commonly used scales for depression.
For example, the HAM-D and the MADRS are evaluated in detail and their clinical and scientific
cross-sectional and longitudinal utility are discussed. It is emphasized that self-rating scales may
have a higher variance than observer-rated scales, which often necessitates larger trial sample
sizes of the observed population in order to achieve statistically significant effects.
A series of fully structured interview schedules and diagnostic instruments developed in
the last decade allow ICD-10 and DSM-5 diagnoses to be generated: the Composite Diagnostic
Interview [17,18], the Structured Clinical Interview for DSM [19,20], and the PSE-based Schedules
for Clinical Assessment in Neuropsychiatry [21,22]. Overall, these instruments seem likely to
lead to a considerable increase in inter-rater reliability in the assessment of mental states and in
diagnostic classification. However, as mentioned above, these fully structured instruments are
often too time-consuming and expensive for everyday clinical use. They are primarily indicated
for diagnosing depression or different types of depression, and not simply for assessing the
severity of depression or the course of severity.
Use of scales in pediatric depression

The assessment of pediatric depression is a challenge, as the apparent symptoms are often a
topic for interpretation rather than assessment. Chapter 4 describes the different scales used
for pediatric depression and discusses their usefulness for establishing treatment options for
this group of patients. Early and accurate diagnosis is especially important to this population
because longer duration of untreated illness in children and adolescents has been linked to
more frequent recurrences which, together with emerging difficulties in the development of
psychosocial and emotional skills, can lead to poor outcomes [23].
Use of scales in elderly depression

The assessment of depression in geriatric patients is described in Chapter 5. Various factors
complicate the assessment of depression in cognitively impaired patients or those with
dementia because symptoms of depression can overlap with behavioral manifestations such
as apathy and loss of initiative. Furthermore, in patients with dementia, depressive symptoms
may fluctuate over time or fail to meet the criteria for intensity, duration, or functional impact
required for a diagnosis of major depression (eg, DSM-5) [1]. Therefore, when assessing
symptoms in late-life depression, more specific scales such as the Dementia Mood Assessment
Scale or the Cornell Scale for Depression in Dementia may be considered [24,25].
The scales reviewed in this book reflect the most important contemporary assessment
tools used in depression, including those scales for populations spanning the lifespan. The aim
of this book is to provide a clinically relevant resource that a busy clinician can pragmatically
use to evaluate the patient. Additionally, the information in the book will enhance
understanding of the psychosocial situation and aid in interpreting the responses a patient
and/or their relatives give to describe the patient’s current mental state.
References
1 World Health Organization (WHO). International Classification of Diseases. WHO website. www.who.int/
classifications/icd/en/. Accessed August 29, 2014.
2 American Psychiatric Association (APA). Diagnostic and Statistical Manual of Mental Disorders. 5th edn.
Arlington, VA: American Psychiatric Publishing; 2013.
3 Hamilton M. A rating scale for depression. J Neurol Neurosurg Psychiatry. 1960;23:56-62.
4 Montgomery SA, Åsberg M. A new depression scale designed to be sensitive to change. Br J Psychiatry.
1979;134:382-389.
5 Cairns V, Faltermaier T, Wittchen HU, et al. Some problems concerning the reliability and structure of the
scales in the inpatient multidimensional psychiatric scale (IMPS). Arch Psychiatr Nervenkr. 1982; 232:395-406.
6 Cairns V, von Zerssen D, Stutte KH et al. The stability of the symptom groupings in the Inpatient
Multidimensional Psychiatric Scale (IMPS). J Psychiatr Res. 1982;17:19-28.
7 Gebhardt R, Pietzcker A, Freudenthal K, et al. [Building syndromes in the AMP-system (author’s transl)].
Arch Psychiatr Nervenkr. 1981;231:93-109.
8 Lorr M, Mc ND, Klett CJ, et al. Evidence of ten psychotic syndromes. J Consult Psychol. 1962; 26:185-189.
I ntr o ducti o n to assessment in depressi o n 5
9 Mombour W. [Frequency of symptoms in psychiatric illnesses. A comparative investigation with two

rating scales (IMPS and AMP-scale)--psychological-pathological findings (author’s transl)]. Arch Psychiatr
Nervenkr. 1974;219:133-152.
10 Mombour W. [Syndromes in psychiatric illnesses. A comparative investigation with two rating scales
(IMPS and AMP-scale) (author’s transl)]. Arch Psychiatr Nervenkr. 1974;219:331-350.
11 Baumann U, Stieglitz RD. Testmanual zum AMDPSystem. Empirische Studien zur Psychopathologie.
Berlin: Springer; 1983.
12 Moller HJ, Hacker H. Study concerning the sample dependency and temporal variance of the factor
structure in the Inpatient Multidimensional Psychiatric Scale. Psychopathology. 1988;21:281-290.
13 Steinmeyer EM, Moller HJ. Facet theoretic analysis of the Hamilton-D scale. J Affect Disord. 1992;25:53-61.
14 Calabrese JR, Bowden CL, Sachs GS et al. A double-blind placebo-controlled study of lamotrigine
monotherapy in outpatients with bipolar I depression. Lamictal 602 Study Group. J Clin Psychiatry.
1999;60:79-88.
15 Moller HJ. Standardised rating scales in psychiatry: methodological basis, their possibilities and
limitations and descriptions of important rating scales. World J Biol Psychiatry. 2009;10:6-26.
16 Jablensky N, Sartorius N, Gulbinat W et al. The WHO instruments for the assessment of depressive
disorders. In: Assessment of Depression. Edited by Sartorius N, Ban TA. Berlin: Springer; 1986;61-81.
17 Wittchen HU, Semmler G. Composite International Diagnostic Interview (CIDI, version 1.0). Weinheim:
Beltz; 1991.
18 Wittchen HU, Semmler G. Composite International Diagnostic Interview (CIDI, version 2.0). Weinheim:
Beltz, 1997.
19 Wittchen HU, Wunderlich U, Gruschwitz S et al. Strukturiertes Klinisches Interview für DSM-IV (SKID).
Göttingen: Hogrefe; 1997.
20 Wittchen HU, Zaudig M, Spengler P. Wie zuverlässig ist operationalisierte Diagnostik? Die Test-Retest
Reliabilität des Strukturierten Interviews für DSM-III-R. Z Klin Psychol. 1991;20:136-153.
21 World Health Organization (WHO). Schedule for the clinical assessment in neuropsychiatry. Geneva:
WHO; 1991.
22 WHO. Schedule for the clinical assessment in neuropsychiatry. Version 2.1. Geneva: WHO; 1999.
23 Cullen K, Klimes-Dougan B, Kumra S, Schulz SC. Paediatric major depressive disorder: neurobiology and
implications for early intervention. Early Interv Psychiatry. 2009;3:178-188.
24 Sunderland T, Hill JL, Lawlor BA, Molchan SE. NIMH Dementia Mood Assessment Scale (DMAS).
Psychopharmacol Bull. 1988;24:747-753.
25 Alexopoulos GS, Abrams RC, Young RC, Shamoian CA. Cornell Scale for Depression in Dementia. Biol
Psychiatry. 1988;23:271-284.
2. Observer rating scales
Introduction
Observer rating scales (also called observer rating scales, observer scales, or clinical scales)
relate to past or current behavior and experiences [1]. These standardized scales are used
to rate the extent of psychopathological phenomena and may focus on a single aspect of
psychopathology (unidimensional scales) or on several aspects (multidimensional scales). For
example, to evaluate only the severity of depression, a unidimensional scale is sufficient. To
assess other symptom dimensions, such as anxiety and obsessive-compulsive and psychotic
symptoms, a multidimensional scale or a combination of different unidimensional scales is
indicated. In a long-term study on patients with depression, a broad range multidimensional
scale like the Association for Methodology and Documentation in Psychiatry (AMDP) system
[2] might be indicated in order to record mood switches (eg, to manic or psychotic symptoms),
despite the focus of the study being on depression [3]. It should be noted that even if the
name of a scale appears to indicate that it is unidimensional and focuses on one syndrome or
disorder, the scale is very often not actually unidimensional, but multidimensional; this is true
for the Hamilton Depression Rating Scale (HAM-D) [4,5].
General aspects of observer rating scales

For each aspect of psychopathology, the assessment may be based on a global rating or
on different elements within the aspect being assessed (eg, individual symptoms of the
depressive syndrome). In the latter case, the overall score of the instrument is obtained by
summing values for these different elements.
Standardization
Assessment or rating scales do not have a uniform level of standardization. Standardization for
most of these instruments is limited to providing guidelines that describe the items and the
DOI 10.1007/978-3-319-04627-3_2
categories used to assess them and specifying a method to analyze the assessments. Generally,
a total score or summary scores (consisting of a total score and subscores) are calculated. For
some scales, a time frame and the framework in which the observation should take place
are stipulated for the assessment. In the latter case, the instrument is referred to as a fully
structured or standardized interview. The more extensive the standardization procedures, the
more reliable an assessment instrument generally becomes. However, a highly standardized
instrument tends to become less practicable. As a result, for pragmatic reasons the non-fully
structured instruments (ie, the typical clinical rating scales such as the HAM-D) are preferred
to fully structured instruments in both everyday clinical use and research because they can
be completed after a routine psychiatric interview. The inter-rater reliability of these simpler
clinical rating scales is lower than that of fully structured assessment instruments. However, this
disadvantage can be at least partially compensated for by systematic joint training of raters, as
is the case in clinical trials for drug evaluation.
Symptom assessment
In observer rating instruments, psychopathological phenomena (symptoms) are identified
by trained raters (eg, doctors, psychologists, care staff, lay people trained to administer the
instrument) or by relevant others (eg, partner, relatives, friends). The assessment refers to
the behavior and/or experience of the patient and is based on the rater’s own observations,
information given by the patient or both. Observer rating scales need to be constructed in a
way that makes them suitable for the interviewers who will administer them. Thus, some
scales are designed for doctors or psychologists trained in psychiatry (eg, Montgomery-
Åsberg Depression Rating Scale [MADRS] [6]), while others are designed for care staff trained in
psychiatry or for patients’ relatives.
Observer rating scales mainly focus on the psychopathological state. The aim of the scale
may be to classify each individual wholly as a ‘case’ or ‘non-case’ [7], record specific aspects of the
patient’s mental state [8,9], or assess the whole spectrum of psychopathology (eg, AMDP system).
The more syndromes that are represented in a scale, the wider the range of its potential
applications will be. For example, a comprehensive multidimensional scale like the AMDP
system [2] covers a wide range of symptoms and syndromes characteristic for different mental
disorders, including depression. Such a comprehensive scale is useful as part of a clinical basic
documentation system that covers all kinds of patients, for example, or in a long-term follow-
up study in which patients can be expected to switch into different syndromes (eg, from mania
into bipolar depression and vice versa; or from non-psychotic to psychotic major depression
and vice versa). However, in order to address specific issues for which even a comprehensive
scale does not collect enough data (eg, detailed aspects of suicidal behavior), a comprehensive
rating scale should be combined with other specific observer rating scales (eg, the Columbia-
Suicide Severity Rating Scale) [10].
When professionally trained assessors administer observer rating instruments, they
decide how much weight to put on the information the patient gives. In addition, observable
Observer rating scales 9
changes are taken into account in the rating, for example an improvement in general
behavior and demeanor, even if the patient gives no clear report of this improvement. An
advantage of this expert assessment is that it reduces the scope for inaccurate assessments
resulting from distortions in patients’ perception of themselves. However, it does introduce
the risk of distortion related to the assessor (rater bias). Systematic distortion in the assessor’s
observations [11] can result from the following factors in particular:
•• Rosenthal effect: The assessor’s expectations influence the result of the assessment;
tendency on the part of the assessor to systematically over- or under-rate the degree of
disturbance;
•• Halo effect: The results of the assessment of one characteristic are influenced by the
assessor’s knowledge of the patient’s other characteristics or by the overall impression
made by the patient; and/or
•• Logical errors: The result of the assessment is influenced by assessors reporting only
those detailed observations that make sense to them in the context of their theoretical
and logical preconceptions. These errors may be partially compensated for by combining
observer rating scales with self-rated scales [1].
Most rating scales allow the current mental state to be described. When performed at intervals,
they can also be used to examine changes over time, although they were not originally
specifically developed for such use. During further development of the scales, changes
over time were rather studied with sophisticated statistical analyses focusing on the item
development and internal structure of the item association over time and whether the total
score of all items or a subset of items always reflect severity in the same way [12,13].
Of interest, especially in the context of psychopharmacological studies, is the administration
of observer rating scales like the HAM-D with a telephone-based interactive voice recording
system (IVRS), rather than in a face-to-face interview [14–16]. The IVRS can increase reliability and
is cost-effective. However, when administered via such a system, the HAM-D is technically no
longer being used as a true observer rating scale (ie, although information given by the patient
is being assessed, the expert interpretation of this information and clinical observation of
depression-related behavior changes such as facial expression are lacking). When used with this
new approach, the process becomes similar to a self-rating procedure, with all of its limitations
(see Chapter 3).
Examples of observer rating scales for depression

Several observer rating scales for depression are available; the most traditional and probably
the first to be developed, the HAM-D, has been in use for more than 50 years [4,17]. Nearly all
antidepressants have been evaluated on the basis of the HAM-D. Although often criticized for
several reasons [18], this scale has remained popular for both the evaluation of antidepressants
in clinical studies and for other clinical purposes [19]. This scale has an obvious face validity
for all doctors trained in psychiatry when they consider its rich coverage of clinically relevant
depression symptoms. In comparison, the MADRS is a more modern scale that has certain
advantages such as its shortness (10 items), sensitivity to change, and lack of bias for sedating
antidepressants. This lack of bias has resulted in the MADRS being used in many drug trials
evaluating modern antidepressants.
Several other depression scales are available [1] that are used under certain conditions or
in certain countries, but none are used as widely as the HAM-D and MADRS. Some depression
scales were developed in the USA that tended to be primarily based on the symptoms in the
Diagnostic and Statistical Manual of Mental Disorders (DSM)-IV description of major depression, for
example [20,21]. Although these scales have demonstrated their clinical usefulness in a few larger
North American studies such as the Sequenced Treatment Alternatives to Relieve Depression
or Systematic Treatment Enhancement Program for Bipolar Disorder, they have not yet become
globally accepted. However, the Inventory of Depressive Symptomatology from Rush et al [20]
and its respective short version, the Quick Inventory of Depressive Symptomatology [22], might
gain wider acceptance in the future. The HAM-D and MADRS are described in detail below. The
description includes information on how to use each scale and how it was constructed and
psychometrically evaluated, which demonstrates the quality standards of the scale.
In addition to the mental state, domains such as social adjustment may also be measured
by observer rating scales. The assessment of social functioning is a useful additional outcome
dimension because it helps obtain a full picture of a patient’s problems and burdens. Examples
include:
• Social Adjustment Scale (SAS) [23];
• Social Interview Schedule (SIS) [24,25];
• World Health Organization Disability Assessment Schedule (WHODAS) [26];
• Global Assessment Scale (GAS) [27];
• Social and Occupational Functioning Assessment Scale (SOFAS) [28]; and
• Personal and Social Performance Scale [29]
The dimension of social functioning is complementary to the assessment of depressive
symptoms; both ratings are only partially intercorrelated, depending on the respective
dimension of psychopathology and social functioning [30].
Featured scale: Hamilton Rating Scale for Depression

The HAM-D [4,5,9] was one of the first observer rating scales for depression to gain worldwide
acceptance, although its weaknesses have been increasingly criticized [31,32]. The item
scoring sheets of the original 17-item version and the 24-item version of this scale are shown
in Tables 2.1 and 2.2 (see Appendix A for the full scale) [33,34].
How to use the Hamilton Rating Scale for Depression

This observer rating scale is designed to be used by doctors or psychologists trained in
psychiatry and with sufficient clinical experience. The rater evaluates the severity of the
Scoring sheet for the original, 17-item version of the Hamilton Depression (HAM-D) Rating Scale
Number Symptom Score

1* Depressed mood 0–4
2* Low self-esteem, guilt 0–4
3 Suicidal thoughts 0–4
4 Insomnia: initial 0–2
5 Insomnia: middle 0–2
6 Insomnia: late 0–2
7* Work and interests 0–4
8* Psychomotor retardation 0–4
9 Psychomotor agitation 0–4
10* Anxiety, psychic 0–4
11 Anxiety, somatic 0–4
12 Gastrointestinal symptoms (appetite) 0–2
13* Somatic symptoms, general 0–2
14 Sexual disturbances 0–2
15 Hypochondriasis (somatization) 0–4
16 Insight 0–3
17 Weight loss 0–2
Total score: 0–53
Table 2.1 Scoring sheet for the original, 17-item version of the Hamilton Depression (HAM-D) Rating
Scale. The time frame (window) is the past 3 days. *Depression factor. Adapted with permission from
Hamilton [4,34] ©BMJ.
symptoms on the basis of information obtained during a clinical interview. Additional

information obtained from relatives, friends, nurses and others may also be taken into
consideration to enrich or correct the information given by the patient [34]. The interview,
which is performed like a typical free or non-standardized psychiatric exploration, should
last about 30 minutes to allow time to cover all the relevant points. The scale is intended to
measure the severity of symptoms, not minor fluctuations, and therefore the patient’s
condition during the past few days or the past week should be considered.
To increase inter-rater reliability and to ensure that the scale is administered correctly
(ie, that the items are correctly understood and rated), new users should receive brief training
from raters experienced in using the scale. In research studies, either all patients should be
assessed by two raters, who should discuss discrepant assessments after the rating, or the
whole group of investigators should be given a formal rater training.
The scale measures individual depressive symptoms and their overall severity (reflected in
the total score). Sequential HAM-D ratings are often used to assess the course of depression,
for example in antidepressant studies. Experience has shown that ratings should generally not
Scoring sheet for the 24-item version of the Hamilton Depression (HAM-D) Rating Scale
Number Symptom Range Score

1 Depressed mood 0–4
2 Low self-esteem, guilt 0–4
3 Suicidal thoughts 0–4
4 Insomnia: initial 0–2
5 Insomnia: middle 0–2
6 Insomnia: late 0–2
7 Work and interests 0–4
8 Psychomotor retardation 0–4
9 Psychomotor agitation 0–4
10 Anxiety, psychic 0–4
11 Anxiety, somatic 0–4
12 Gastrointestinal symptoms (appetite) 0–2
13 Somatic symptoms, general 0–2
14 Sexual disturbances 0–2
15 Hypochondriasis (somatization) 0–4
16 Insight 0–2
17 Weight loss 0–2
18 Diurnal variation 0–2
19 Depersonalization and derealization 0–4
20 Paranoid symptoms 0–3
21 Obsessional and compulsive symptoms 0–2
22 Helplessness 0–4
23 Hopelessness 0–4
24 Worthlessness 0–4
Total score: (0–75)
Table 2.2 Scoring sheet for the 24-item version of the Hamilton Depression (HAM-D) Rating Scale.
Adapted with permission from Hamilton [4,33] ©BMJ.
be repeated at intervals shorter than 7 days. At repeat interviews, questions about changes
in symptoms should be avoided. Also, before interviewing a patient, interviewers should not
review the results of the previous rating.
The original scale contains 17 items [4], but 21- and 24-item scales were later
developed [33]. Nevertheless, the original 17-item scale is used in and recommended for most
psychopharmacological studies. Publications should always give details of the particular version
of the scale that was used in a study because the score ranges for some items can vary. If no
specific version is named, the reader can assume that the standard version was applied.
The degree of symptom severity is operationally defined for most of the items, which
means that the rater must make the assessment on the basis of the content of specific
statements and the tone, facial expression and gestures of the patient during the interview;
the remaining items depend on a subjective selection of one of a number of levels of severity
ranging from ‘absent’ to ‘severe’ or ‘incapacitating’. Most of the items have a three-level score
(0–2), the remaining ones a four- (0–3) or five-level (0–4) score, depending on the version of the
scale being used. Symptom severity and frequency of symptoms should both be considered in
the scoring. The total score of the HAM-D-17 ranges from 0–52 or 53 (depending on the version
used), that of the HAM-D-21 from 0–64 and that of the HAM-D-24 from 0–76.
Quality and characteristics of the Hamilton Rating Scale for Depression

From a clinical standpoint, the type and spectrum of items characterizing depression seems prima
facie meaningful: the items cover the traditional concept of depression, primarily the concept of
endogenous depression, and are not influenced by the modern diagnostic classification systems.
Somatic symptoms are more broadly represented than affective and cognitive symptoms. Some
symptoms such as retardation (item 8) are relatively broad and include cognition, language, and
motor activity. Symptoms typical for atypical depression such as hypersomnia and increased
appetite or weight cannot be assessed because the scale only asks about changes in the
opposite direction (ie, insomnia, reduced appetite, and weight loss). It is questionable whether
the characteristic ‘diurnal variations’, which is included in the 21- and 24-item versions, should
actually result in a higher depression score. The inclusion of this item can lead to contradictions
in the diagnosis of the course of the disease because clinical experience shows that the most
severe endogenous depressions often show no diurnal variations at first and that these only occur
upon improvement of the severe depressive mood. The fact that three items rate sleep disorders
(insomnia early, middle, and late) leads to an efficacy bias in antidepressant studies in favor of
sedating or sleep-inducing antidepressants. Experts have discussed whether the slight efficacy
advantage of tricyclic antidepressants over selective serotonin reuptake inhibitors (SSRIs) found
in some studies and in meta-analyses might have been due to a bias of the HAM-D to capture
sleep-inducing, sedating, and anxiolytic properties [35–37].
In addition to the possibility to calculate a total score, factor scores can also be calculated
during the final analysis [4]. However, the results of factor analytical evaluations of the scale
resulted in different solutions of 2 to 6 factors (which is not unusual for other rating scales in
psychiatry) [4,9,38].
The inter-rater reliability is high to very high, at least for the total score, depending on the
experience and training of the raters [4,39,40]. The retest reliability is also high [41].
Suggestions were made to define items and assessment criteria more explicitly, in order
to increase the inter-rater reliability [42]. Consequently, a Structured Interview Guide was
developed for the HAM-D (SIG-H) [41]; the guide has become quite well accepted in Anglo-
American countries. However, when the interview guide is used, the HAM-D can no longer be
seen as a rating scale but rather as a fully structured interview. As a result, it becomes more
time consuming and no longer fits into the typical communication situation with the patient in
a clinical setting and thus induces a somewhat artificial situation.
The HAM-D total score correlates well with the Clinical Global Impression rating of
depression and with the total score of other depression scales, indicating its convergent
validity [43–45]. As for discriminant validity, the HAM-D correlates moderately well with anxiety
scales but the discrimination could be better. However, this finding is similar to that for other
depression scales and has been a point of general criticism [46].
The sensitivity of the HAM-D to detect antidepressant-induced changes has been
demonstrated in numerous antidepressant studies [47,48] (Figure 2.1) and, recently, in
psychotherapy studies [49,50]. The good sensitivity to change can be interpreted as a strong
indicator of validity. Reference values for various clinical samples are available [34], but norm
values from a representative healthy population are not, as is also the case for most other
clinical observer scales. A literature review of control groups in clinical studies of depression
reported a mean HAM-D-17 score of 3.2 (SD 3.2) among healthy control individuals [51].
Improvement of the Hamilton Depression (HAM-D) Rating Scale total score in severely depressed
patients treated with agomelatine
22 ∆ = 2.86±0.56 ∆ = 3.00±0.64 ∆ = 3.48±0.72 ∆ = 4.53±1.31
20
18
HAM-D total score
16 ***
*** ***
14 ***
12
10
Total HAM-D≥25 HAM-D≥25 HAM-D≥30
population CGI-S≥5
n = 72 358 363 295 296 225 232 76
Agomelatine 25–50 mg Placebo ***P<0.001
Figure 2.1 Improvement of the Hamilton Depression (HAM-D) Rating Scale total score in severely
depressed patients treated with agomelatine. Dose of 25–50 mg/day for 6–8 weeks (meta-analysis of
three positive studies) according to three severity criteria (HAM-D ≥25; HAM-D ≥25 and CGI-S ≥5; HAM-D
≥30). Reproduced with permission from Montgomery and Kasper [48] ©Lippincott, Williams and Wilkins.
Some additional problems of the scale still remain unresolved; for example, it does not
record certain diagnostically specific areas that are partially included in other depression scales,
such as the Inventory of Depressive Symptomatology (IDS) [28] (which includes symptoms
of atypical depression) and, therefore, proves to be unsatisfactory for some subtypes of
depression. The IDS is an extended version of the HAM-D and includes all DSM symptoms of
major depression. It has 28 items (a more recent version has 30 items) and is available as an
observer rating (IDS-C) and self-rated (IDS-SR) scale [52,53].
The HAM-D was subjected to critical test-theoretical analyses, including some performed
according to the Rasch model and the facet analytical model, in order to investigate its
homogeneity and the stability of the factor structure in repeated measurements during
treatment and to find a minimal number of items that adequately reflect severity at different
times [20,21,54]. The analyses resulted in a list of unidimensional core items. On the basis of this
search for core items with optimal psychometric properties, short versions of the HAM-D were
developed to assess depressive symptom severity:
•• the Bech six-item version [55];
•• a similar six-item version suggested by Maier and Philipp [56]; and
•• a seven-item version of the HAM-D (HAM-D-7; [57,58]).
The Bech six-item version showed that this approach might lead to better results than the full-
length version of the HAM-D in terms of differentiating antidepressant effects from those of
placebo [59]. Other studies also found positive results for the Bech six-item version and other
similar short versions [60,61]. Faries et al [62] and Entsuah et al [63] suggested that the use of
such an unidimensional short scale requires fewer patients than the full HAM-D-17 scale. Also,
such a scale may better detect the real antidepressant effect, independent of sedative and
anxiolytic properties of the antidepressant [35]. On the basis of further analyses and clinical
reflections, the Bech-Rafaelsen Melancholia Scale was developed (BRMES) [21,64], which
consists of 11 items, 6 of which are in the Bech six-item version of the HAM-D.
For pragmatic and other reasons, self-rating versions of the original HAM-D were
developed (eg, the Caroll Self-rating Scale for Depression [CDRS] and the Hamilton Depression
Inventory [HDI] [65,66]). The latter scale has additional items and increased application
possibilities, including a PC version [67] and an interactive voice response (IVR) version [68].
Self-rating versions were also developed from abbreviated versions [33,69].
In addition to reporting mean score changes, drug treatment studies in depression
have increasingly focused on using remission as a relevant categorical efficacy criterion.
In accordance with Frank et al [70], Rush et al [53] found on the basis of receiver operating
characteristic (ROC) analyses of data from patients with major depression, healthy controls,
and remitted patients that a HAM-D-17 score ≤7 (which corresponds to a HAM-D-7 score ≤3;
[57]) is a meaningful criterion for remission [53]. The ACNP Task Force [71] recommended that
if the HAM-D-17 scale is used, a score of ≤7 or ≤5 should be used as the criterion for remission.
However, recent evidence supports the use of even more stringent remission criterion
scores for both the HAM-D and MADRS scales [72]. A criticism of the use of response (in the
common definition: 50% reduction from the baseline score) as an outcome measure is that it
can identify a highly heterogeneous population of patients. However, defining remission with
the suggested HAM-D-17 cut-off scores or even more stringent ones identifies populations of
remitters that are as heterogeneous as the population of responders in terms of psychosocial
impairment [73,74]. Patients with a HAM-D-17 score ≤2, for example, show better psychological
functioning than those with scores of 3 to 7 [75,76].
Featured scale: Montgomery-Åsberg Depression

Rating Scale
Although the HAM-D is still widely accepted and supported by a long tradition and enormous
database in terms of psychometric evaluation and repeated use in all kinds of studies, the
MADRS [6] is becoming an increasingly important observer rating scale thanks to its conciseness,
better definition of items, ease of use, and modern approach to test construction (according to
the principle of sensitivity to change). The sensitivity to change aspect seems to support its use in
treatment-related studies. Contrary to the HAM-D, which covers a broad spectrum of depressive
symptoms, the MADRS includes only the following ten items:
•• apparent sadness;
•• reported sadness;
•• inner tension;
•• reduced sleep;
•• reduced appetite;
•• concentration difficulties;
•• lassitude;
•• inability to feel;
•• pessimistic thoughts; and
•• suicidal thoughts.
How to use the Montgomery-Åsberg Depression Rating Scale

The scale (Appendix B) should be used by doctors or psychologists trained in psychiatry who
have sufficient clinical experience. The ten items are assessed on the basis of a clinical interview
and observation. The interview should begin with more general questions and lead on to
detailed symptoms. If the patient does not give exact answers, all relevant information from
other sources should be integrated into the final evaluation. About 15 minutes seem to be
sufficient for the interview. The rating time and length of the interview should be fixed if the
scale is used to study the longitudinal course of depressive symptoms.
Each item is rated on a seven-point scale (0–6). Descriptions are given for points 0, 2, 4, and
6 on the scale as anchor points. In the analysis, the scores for each item are summed to give a
total score, which can range from 0–60 points. A less expensive version of the scale, which does
not include the anchor points, is available and has demonstrated validity and clinical utility [77].
The scale is especially indicated for studies on the clinical course of depression during
treatment because it focuses on depression severity and does not cover a broad spectrum of
depression symptoms. It is a very economical approach for such settings, given the limited
number of items and short duration of the interview. The precise wording of the items
guarantees good inter-rater reliability without intensive rater training. Other scales, such as the
HAM-D, are preferable if a broader spectrum of symptoms needs to be covered.
Quality and characteristics of the Montgomery-Åsberg Depression Rating Scale

The original selection of items was based on the Comprehensive Psychopathological Rating
Scale (CPRS) [78], which indicates the content validity. On the basis of frequency analyses and
by selecting the items that showed the highest change score and correlated most strongly
with the change in the total score, the original number of items related to depression was
reduced to ten. The scale includes the main symptoms of depressive illness and most of the
DSM criteria for depression, even though certain important areas (eg, psychomotor retardation,
tendency to somatize) have been omitted as a result of the method of item selection [79].
As to other aspects of content validity, the scale correlates well with the HAM-D [6,45],
especially with the first factor of the HAM-D. Meier et al [46] found a correlation between the
MADRS and HAM-D-17 total scores of r=0.85 and between the MADRS and HAM-D-21 total
scores of 0.83. Overall, factor analyses and correlations with the HAM-D (particularly with the
various subscales) show that the MADRS covers more purely psychological symptoms than
the HAM-D [6,79–86]. In these analyses, the dimensions covered by the MADRS items were
classified under the headings sadness/pessimistic thoughts, inner tension, inability to feel and
reduced appetite. Although the scale does not seem to be unidimensional, it should be noted
that more of the MADRS items are loaded on the first factor than are the HAM-D items.
The Rasch model indicated that the MADRS seems to ensure invariance of meaning across
different subgroups and also longitudinally [55,80]. As to its discriminant validity, a point of
criticism is its only moderate correlation (0.42) with an anxiety scale, the Covi Anxiety Scale [46],
and with different subscales of the Positive and Negative Syndrome Scale (PANSS; eg, 0.51 with
the PANSS negative subscale) [87].
In the studies performed while the scale was being constructed, the sensitivity to
change was claimed to be better than that of other procedures used simultaneously [88–90].
In later studies, the sensitivity of the MADRS for differences in the severity of depression [79]
and change in depression symptoms was again shown to be good [80,91,92]. However, when
the mean score values of the MADRS were compared with those of the HAM-D in a large
sample of inpatients with major depressive disorder, the course appeared to be relatively
similar, apart from the higher mean values of the MADRS [93] (Figure 2.2). The effect sizes in
placebo-controlled antidepressant efficacy studies were similar to those of the HAM-D-17
scale [94] or slightly better [85,95].
Reference values are available for several clinical samples [80,81], but norm values for the
general population are not, as is the case for most scales.
Mean value courses (last observation carried forward [LOCF]) of Hamilton Depression Rating Scale-17 and
Montgomery-Åsberg Depression Rating Scale over 10 weeks in 1014 naturalistically treated inpatients
with a major depressive episode
35 MADRS
HAM-D-17
30
Mean item scores (LOCF)
25
20
15
10
5
0 2 4 6 8 10
Week
Figure 2.2  Mean value courses (last observation carried forward [LOCF]) of Hamilton Depression
Rating Scale-17 and Montgomery-Åsberg Depression Rating Scale over 10 weeks in 1014
naturalistically treated inpatients with a major depressive episode. Reproduced with permission from
Seemuller et al [93] ©Elsevier.
The inter-rater reliability has been presented for different samples and been shown to be
high, with values of 0.89 to 0.97 [6,88]. It was found to be slightly lower in studies that included
different professions (psychiatrists, psychologists, nurses) working in psychiatry [80], whereby
ratings by nurses showed the lowest inter-rater reliability. The correlation with the Clinical
Global Impression of Severity was approximately 0.70 in two studies [45,84]. As mentioned
above, drug treatment studies in depression are increasingly using remission as a relevant
categorical efficacy criterion. Various suggestions have been made for the remission cut-off
score for the MADRS scale: ≤8 [96], <10 [97], or ≤10 [98].
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3. Self-rating scales
General aspects of self-rating scales

Patients use self-rating instruments to describe past or current behavior and experiences [1-
4]. Self-rated scales are a cost-effective way for the doctor or researcher to obtain information
about a patient’s mental state and eliminate observer bias. However, like observer ratings (see
Chapter 2), self-rating scales can also be distorted, although for different reasons which will be
discussed later in this chapter. Generally, self-ratings are more subjective; however, observer
ratings are also not fully objective. The main disadvantages of self-rating scales are as follows:
•• conscious or unconscious tendencies might falsify responses (eg, tendencies to
exaggerate or conceal symptoms); and
•• positive response bias and social desirability effects.
These disadvantages can seriously affect the findings of self-rating instruments. Several factors
might be involved, such as personality traits; for example, higher neuroticism generally leads to
higher scores on self-rating depression scales or related complaints lists [5]. Also, the severity
of the mental disorder can affect results. For example, severely depressed patients often
underestimate the severity of their depression, while mildly depressed patients overestimate
it [5]. The latter case may have consequences in a treatment study, for example when the
participants’ mental condition appears to improve over the course of treatment if scales are
used as the determinant. Such tendencies are only partially detectable through the use of
control scales, which are commonly used, especially in personality tests (which are based on
self-ratings).
Another disadvantage of self-rating scales is that they usually have a higher variance than
observer rating scales. Consequently, if self-rating instruments are used, sample sizes need to
be larger in order for the study to achieve statistical significance. At present, drug authorities do
not accept the results of self-rating scales as the only outcome measurement in drug studies
for several reasons, including those mentioned above.
DOI 10.1007/978-3-319-04627-3_3
Because of all these limitations, a careful decision needs to be made whether or not
to use a self-rating scale for depression and whether the scale will be used alone or with
an observer rating scale. A self-rating might be sufficiently valid as a screening test for
depression (eg, the Major Depression Inventory [MDI] questionnaire [1,6], which is based on
the MDI observer rating, or the depression-related part of the Patient Health Questionnaire
[PHQ-9] [7], or even quite short self-ratings that do not directly focus on the concept of
depression but rather on well-being, such as the World Health Organization [WHO]-Five
Well-being Index [1]). A self-rating scale may also be used to measure treatment effects
in depression, as was done for example in the North American Sequenced Treatment
Alternatives to Relieve Depression (STAR*D) study [8], to evaluate the severity of depression
cross-sectionally or the course of depression longitudinally during routine patient care.
However, for more sophisticated research studies, especially clinical studies for regulatory
approval of an antidepressant, it is advisable to combine a self-rating scale with an observer
rating.
Symptom assessment
Self-assessment procedures are available for assessing the symptoms and syndromes of
depression; examples include the Beck Depression Inventory (BDI) [9] for depressive symptoms
and the Clinical Self-Rating Scales (CSRS) [10–14] and Symptom Checklist-90 (SCL-90), which
will be discussed later in the chapter, for depressive, somatic, and paranoid symptoms [15].
Self-rated scales can also be in the form of visual analogue scales (so-called ‘barometer scales’
on which particular dimensions or current experience are graphically represented); these are
especially useful for intra-individual studies of course over time with a multitude of sequential
measurement points [16,17].
Apart from a few scales that measure a broad spectrum of subjectively experienced
alterations in the current mental state (eg, SCL-90), most self-rated scales focus on specific
aspects of disturbance of subjective experience. Examples are depressive symptom scales
[13,18,19], anxiety symptoms scales [20,21] and measures of current mood or subjective well-
being [1,11]. One of the advantages of this approach is that the quantity of items is limited, a
particular strength when severely disturbed psychiatric patients are being evaluated.
In order to obtain a sufficiently clear subjective view of the current psychological state, it is
always preferable to present not only a checklist of adjectives describing complaints, but also
a symptom-oriented scale (eg, Self-Rating Depression Scale [SRDS]) [19], which is more closely
linked to the symptom-oriented, observer rating approach. However, a precise differentiation
between different aspects of the ‘subjective state’ is generally not useful compared to the
detailed measurement of psychological disturbances by observer evaluation [22]. In fact,
when results from clinical self-rating scales are compared with those of observer-rated scales
administered by specialists, the various dimensions of the subjective state described by self-
Self - rating scales 25
rated instruments seem to be more similar to one another than to the different aspects of
psychopathology delineated by clinical observer-rated assessments.
This finding was supported by a joint factor analysis of data from observer ratings
and self-ratings of mental states [23]. This study applied the Inpatient Multidimensional
Psychiatric Scale (IMPS) [24] as an observer-rated measure and the CSRS [10–14] as a self-
rating measure. The self-assessed data were mainly represented in a single factor (the first to
emerge ) while the observer-rated data were distributed across five further factors. However,
this secondary factor analysis (in which the primary factors derived from the initial analysis of
each scale were also entered as variables) does not demonstrate that self-assessment simply
produces a factor reflecting a global ‘tendency to complain’ rather than a differentiated
picture of subjective impairment. Primary factor analysis of single items from the CSRS and
other self-rating instruments indicates that different dimensions of disturbances, such as
depressiveness, paranoid tendencies and somatic complaints, certainly can be differentiated
on a subjective level. However, the depressiveness factor is closely associated with the
various other types of subjective disturbance. In this context, it should be mentioned that
psychotic symptoms assessed with the SCl-90 seem to be closely correlated with depressive
symptoms and apparently have another meaning than observer-rated psychotic symptoms,
with which they are not closely correlated [25]. A further consideration is that the correlations
between the different dimensions and between their change scores are very high (Möller;
unpublished data), so that the specificity of each of these self-rated dimensions should not be
overinterpreted.
The level of agreement between self-assessment and observer assessment varies and
depends on the type of disturbance and symptom severity [2,26–31]. For example, when
depressive symptomatology is severe, as at the time of inpatient admission, the concordance is
substantially lower than after partial remission of symptoms. This finding is probably associated
with the more limited capacity for self-observation among the severely depressed and also with
the fact that observers tend to identify very severe depressive symptoms to a greater extent on
the basis of non-verbal evidence than they do less severe depressive symptoms, for which the
patients’ verbal reports are more important. Patients with dysthymia (‘neurotic depression’) show
a greater tendency than patients with endogenous depression to overstate their symptoms.
The type of the rating scale (symptom list or adjective scale) and the item selection are of
great importance for the correlation between self-ratings and observer ratings of depressive
symptomatology. One might assume that the best correlation would be obtained if the
selection and wording of the items in the self-rating scale correspond more or less fully with
those in the observer rating scale. However, patients may have difficulty understanding a
direct ‘translation’ of an observer scale into a self-rating version. Some studies on correlations
between self-rating and observer ratings have been performed. For example, the SRDS [19]
correlates only moderately with the Hamilton Depression Rating Scale (HAM-D; r=0.41) [32], as
does the BDI [33] with the self-rating version of the Inventory of Depressive Symptomatology
(IDS-SR) [34]. In contrast, the correlation between the Carroll self-rating version of the HAM-D
(CRS) [35] and the observer rated HAM-D was 0.80. Rush et al reported interestingly high
correlations between the more or less identical observer rating and self-rating versions of the
IDS and between each of them and the HAM-D [36,37]. The degree of concordance between
self-rating and observer rating scales is substantially greater for the amount of change over
time, as measured in longitudinal studies, than when psychopathological phenomena are
recorded at a single point in time [14,38].
It seems plausible that scales with similar items on both self-rating and observer rating
scales might have a higher degree of concordance than an observer-rated symptom scale like
the HAM-D and an adjective mood scale for self-rating, for example. However, because of the
factors mentioned above and a possibly different interpretation of the symptom descriptions
by doctors and patients, and especially because patients usually do not perceive alterations
in, for example, their mimic and motor behavior (which is an important way for doctors to
assess depression), concordance can still be limited even if the symptom selection is similar.
This can lead to relevant differences in score and in categories that depend on the score values
(eg, response or remission criteria) [26,31,39]. This was evident in a study by Rush et al [37] that
compared the percentages of remitters in an antidepressant study by using the IDS-SR-30 and
16-Item Quick Inventory of Depressive Symptomology (QIDS-SR-16) self-rating scales and the
Differences between depressive self-rating and observer rating scales in determining remission
100 IDS-SR-30
90 QIDS-SR-16
HAM-D-24
Percent without remission (%)
80
70
60
50
40
30
20
10
0
0 1 2 3 4 5 6 7 8 9 10 11 12
Weeks
Figure 3.1 Differences between depressive self-rating and observer rating scales in determining
remission. Time to remission as determined by total score at exit for 30-item Inventory of Depressive
Symptomatology, Self-Report [IDS-SR30] (≤14), 16-item Quick Inventory of Depressive Symptomatology, Self-
Report [QIDS-SR-16] (≤6) and 24-item Hamilton Rating Scale for Depression [HAM-D24] (≤8). Reproduced
with permission from Möller et al [38] ©Karger.
HAM-D-24 (Figure 3.1). The difference in remission rates between the two self-rating scales was
relatively low, while the difference in remission rates between the two self-rating scales and
the HAM-D-24 was high and, despite being quite similar to the self-rating results in the first 5
weeks, increased from the sixth to the twelfth week. The results of the first treatment phase of
the STAR*D study are also of interest in this context: while the self-rating with QIDS identified
32% remitters, the HAM-D identified only 27% [8].
As previously mentioned, a combination of self-rated and observer rated scales is the
best approach to ensure that both subjective and objective psychopathological states
are described in a complementary way. Measures of subjective well-being are of particular
interest for treatment assessments with short rating intervals, particularly visual analogue
scales (sometimes called barometer scales) and adjective mood scales. These scales
measure current disturbances of mood and lend themselves especially well to repeated
measurements. Measures of well-being allow a very good description of response to a
therapeutic intervention at the self-assessment level. Modern methods of statistical analysis,
such as some of the procedures developed for time series analysis, allow satisfactory analysis
of such data [40,41].
Examples of self-rating scales in depression

Several self-rating scales for depression are available either as symptom lists or adjective mood
lists. In contrast to the situation with the observer rating scales for depression, where two
scales are predominantly used (HAM-D and Montgomery-Åsberg Depression Scale), no single
self-rating scale is recommended above the others. A possible explanation for this might be
that self-rating scales are used in more varied situations than observer ratings and different self-
rating approaches are meaningful, depending on the respective indication. For example, for a
simple screening, scales such as the PHQ-9 (the depression score), the self-rating version of the
MDI, or even the short WHO-5 Well-being Index might be sufficient. For frequent repetition
of treatment effects in short intervals (eg, daily or even several times a day), an adjective
mood list or barometer scale is optimal, especially when combined with an observer rating
depression score applied at longer intervals (for example, each week) to increase the validity
of the simple self-rating scale being used. For the cross-sectional assessment of depression
severity and documentation of the course of depression under treatment conditions, a more
detailed self-rating scale like the Beck Depression Inventory (BDI) [18,42] or a self-rating version
of the HAM-D [35] might be the best among the self-rating options. The BDI is used in most
psychotherapy studies, especially those on cognitive behavior therapy.
Zung Self-Rating Depression Scale

The Self-Rating Depression Scale (SDS) was developed by Zung [19] in analogy to his observer
rated depression scale, the Depression Status Inventory [43]. Although the SDS has proven
clinical value, it is no longer widely used. The self-rating scale consists of 20 items covering
typical symptoms, experiences and complaints of depressed patients. The frequencies of the
phenomena in the past 7 days are rated on a four-point scale that ranges from 1 (never) to 4
(mostly/always). The sum of the item scores builds the total score. The scale is valid to describe
the cross-sectional severity of depression or, if sequentially applied, the change in severity.
The scale has content validity because of the selection of items, which are characteristic
for depressed patients. Moderate correlations were found with the HAM-D [44], but, as to be
expected, higher correlations (0.70) were found with the self-rated depression scale of the
Minnesota Multiphasic Personality Inventory [45].
Hospital Anxiety and Depression Scale

The Hospital Anxiety and Depression Scale (HADS) was developed by Zigmond and Snaith
[46], mainly for use in patients with depression suffering from a somatic illness (Appendix C).
However, the scale can also be used to assess short- and long-term severity of depression.
The primary intention of the HADS is to focus on the assessment of depression and anxiety in
patients in nonpsychiatric medical institutions, who usually show fewer or less severe mental
disturbances and non-specific symptoms. Depression and anxiety were selected for the scale
because they are the most prevalent mental symptoms in this patient population and are often
difficult to differentiate.
The HADS consists of 14 items related to depression (7 items) and anxiety (7 items);
items are rated on a four-point scale (0–3). The items were selected from the Clinical Anxiety
Scale [47] and the Present State Examination [48]. The depression items are mostly related to
anhedonia, which is considered to be a central aspect of depression. The items are evaluated
regarding frequency or intensity and pre-post change or planned/actual comparison. The item
scores are summed to give either a depression score or an anxiety score (maximum score of
21 for each). Occasionally, a total score is also calculated and interpreted as ‘mental distress’.
During the rating, which takes about 2–6 minutes, the patients evaluate their symptoms and
experiences in the past week. The terms anxiety and depression are not mentioned in the scale
and should also not be mentioned by the respective investigator. If necessary, the items can be
read aloud by an investigator, who then documents the patient’s responses.
The psychometric properties are reported in the review by Bjelland et al [49]. The
interrater reliability over several weeks is in the range of approximately 0.70–0.80, as is to
be expected for slowly changing mood alterations. The content validity is primarily given
through the item selection. However, the depression concept underlying item selection
is more limited than both the traditional clinical concept of depression and the traditional
depression scales and is, therefore, more relevant for a population with minor changes. As
for convergent validity, Zigmond and Snaith reported correlations of 0.54 with anxiety
observer ratings and 0.74 with depression observer ratings [46]. Correlations with respective
self-ratings or observer ratings were also described in later studies [50]. Results regarding
discriminant validity are extremely inconsistent. The original publication from Zigmond and
Snaith [46] described very positive validity results, probably because the authors focused on
the correlation with the respective observer rated dimensions. However, a later study focusing
on correlations with the (self-rated) State Trait Anxiety Inventory (STAI) found that the STAI
correlated to a similar degree with both the anxiety and the depression subscale of the HADS
(approximately 0.60 for both) [51,52].
As to sensitivity to change, only a few medication studies have been performed [53,54],
but several psychosocial studies in patients suffering from cancer or heart disease (see [50]).
Factor analytical studies suggest a two-factor structure with 50–70% of explained variance
[49,50,55]. However, the intercorrelation between the two subscores is moderate to high
(approximately 0.40 to 0.70 ), indicating the close relationship between depressive and
anxiety symptoms [56]. Norms of a representative sample of the general population, as well as
reference values for several clinical samples, are available [57].
90-Item Self-Report Symptom Inventory

The SCL-90 is the revised version of the Hopkins Symptom Check List [15,58–60]. The
scale is used for patients to assess various burdening symptoms. It allows nine ranges of
syndromes to be recorded and was specifically constructed to register the effects of drug
treatment. It has been used in various clinical studies with neuroleptics, tranquilizers and
antidepressants [61,62].
Paranoid Depression Scale

The Paranoid Depression Scale [PDS], which is available in two parallel forms, is composed of
43 items [10–14,63]. It records the degree of subjective impairment resulting from emotional
reduction due to anxious-depressive mood (these items are also on a separate depression
scale) and a distinct cognitive dimension to determine a distrusting attitude and whether
the subject is out of touch with reality. In addition, the scale includes eight control items that
measure disease denial and three items that assess motivation. The values of the individual
items are summarized as factor values.
Indicators of the validity include correlations of the paranoid scale with the criterion of
belonging to a group of schizophrenic patients, correlations of the depression scale with the
criterion of belonging to a group of patients with depressive mood, correlations with relevant
factors of other scales and sensitivity in the recording of therapy-induced changes. The
depression scale is also available as a separate, 16-item scale that does not include the items
of the paranoid scale. Norm values are available for a representative sample of the general
population in Germany and reference values are available for various clinical groups (physically
ill, mixed psychiatric groups, individual psychiatric diagnosis groups).
Adjective Mood Scale

The Adjective Mood Scale (AMS) contains 28 items and is available in two parallel versions [10–
14,63]. It records the degree of current alterations of subjective well-being. The scale is especially
indicated for mood course descriptions with a focus on fast mood alterations. For this reason
the test can be frequently repeated. It is suitable for healthy subjects and physically or mentally
ill patients, particularly mentally ill patients with affective disorders. The values of the individual
items are summed to give a total score, which indicates the impairment in subjective well-being.
High inter- and intraindividual correlations with global assessments of depressive mood and the
sensitivity for recording therapy-induced changes prove the validity. Norm values are available for a
representative sample of the general population of the former West Germany and reference values
are available for various clinical groups.
Featured scale: Beck Depression Inventory

The BDI is a frequently used self-rating scale that was originally developed as an observer
rating scale and further developed into a self-rating instrument shortly thereafter [18,42].
Certain aspects of the scale were then revised to avoid ambiguities in the item formulation,
among other things; a revised version was published in 1987 [64]. The BDI has 21 items and
places a special focus on cognitive aspects of depression; it does not include motor or anxiety-
related items. Internationally, the scale is seen as the standard self-rating scale for depression
in psychotherapy studies [65], perhaps because of its focus on cognitive symptoms, but it is
sometimes also used in antidepressant studies [66]. It is available in several languages and also
as short versions with 13 or 6 items [67–71]. A North American version of the BDI, the BDI-II, was
adapted to the Diagnostic and Statistical Manual of Mental Disorders (DSM)-IV [64].
How to use the Beck Depression Inventory

The items of the scale were selected on the basis of experience with the symptoms of
depressed patients, mostly psychotherapy patients, without considering etiological aspects
or diagnostic systems. The scale covers a broad spectrum of depressive symptoms, especially
those related to mood and cognition.
The scale is completed by the patient and assesses depressive symptoms and the severity
of depression, but does not assign symptoms to diagnostic categories [2,64,68]. The 21 items
are rated on a four-point scale ranging from 0 (symptom is not present) to 3 (symptom is
severe). Patients choose the level that best describes their condition in the past week (or two
weeks in BDI-II) before the rating, including the day of the rating. For most of the items, patients
are asked to compare their current state to a former one and to rate how much the item has
improved or worsened. For most of the other items the cross-sectional degree of intensity has
to be assessed directly. The total score can range from 0 to 63. Subscales can be used in addition
to the total score to answer special research questions, for example a cognitive-affective
or somatovegetative subscale. Such subscales are composed either on the basis of clinical
considerations or by using a Rasch analysis approach to identify homogenous item groups.
Patients usually need 10–20 minutes to perform the self-rating. Besides the typical self-
rating procedure, it is possible for the investigator to read the items out loud and record the
patient’s answers. When using this approach, one has to be careful that the investigator does
not introduce any bias. To analyze the inventory, all item scores are summed up to a total score.
In case of double crosses for individual items, always the highest score should be considered.
Quality and characteristics of the Beck Depression Inventory

The reliability and validity of the BDI are satisfactory [68,72,73]. The convergent validity with
other self-rating scales is also relatively good; for example, the correlation with the Zung SDS
is 0.72 [74]. The correlation with the observer rated HAM-D is lower (approximately 0.30 to 0.40;
[75]), as would be expected, although some North American studies found higher correlation
values [72]. As to discriminant validity, the scale’s moderate correlations with anxiety scales are
a point of criticism. However, the correlations between observer- and self-rated anxiety scales
are always lower than between observer- and self-rated depression scores [76]. Furthermore,
other self-rating depression scales and even observer rating scales for depression or anxiety
also have problems with discriminant validity. The sensitivity for treatment-induced changes
was demonstrated in several studies (see the meta-analysis by Cuijpers et al [64]).
Factorial analyses have consistently found that a ‘general factor’ exists, with loadings
primarily on the cognitive items. Two- to seven-factor solutions were described without
showing much concordance. A facet analysis described three core items: sadness,
dissatisfaction and irritability; the analysis indicated that most of the other items can be
considered as additive ingredients to these core items, while vegetative symptoms play only a
marginal role [76]. Reference values for different clinical groups are available, but norms from a
representative population are not.
References
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4. Assessment of pediatric depression
Marta Bravo, María Mayoral, Alejandra Teresa Laorden,
Carmen Moreno
General aspects of pediatric depression scales

Major depressive disorder (MDD) may have a worse prognosis when onset occurs during
childhood or adolescence, due to its association with long-term mental and physical health
problems that persist into adulthood [1]. In fact, adolescent-onset MDD is associated with
more suicide attempts, high risk of recurrence of major depression by young adulthood,
early pregnancy, poor school performance, impaired work and social skills, impaired family
functioning, and substance abuse during young adulthood [2,3].
Lifetime prevalence of MDD during adolescence is close to 8% and it is more common
among girls than boys (11.1% vs 4.3%). Data on point prevalence are more heterogeneous, but
the differential distribution prevails, with almost double the prevalence in boys as compared
with girls [4]. In young people under the age of 13, the prevalence is significantly lower —
approximately 3% between 12 and 14 years of age and much lower in younger children — and
equally distributed between the sexes [5]. In medical settings, prevalence figures may even be
double [5]. Sub-threshold symptoms may also have a significant impact on the development of
social and vocational skills.
Depression in adults is primarily characterized by persistent sad mood or irritability and/
or loss of interest or pleasure in activities that were previously enjoyed [6]. The clinical picture
in the juvenile population is quite different and, overall, symptoms of depression vary with
age. In children and younger adolescents, somatic symptoms, anxiety, and irritability are
more prevalent than sadness, whereas in older adolescents the clinical picture is closer to the
adult presentation, with predominance of affective and cognitive symptoms. Furthermore,
depressed young people experience high comorbidity rates, including anxiety disorders,
substance abuse, disruptive behavior disorders, and medical illnesses [7]. Association with
suicidality is particularly prevalent. Some studies have found that 20–24% of adolescents with
MDD attempt suicide, whereas 25–66% report suicidal ideation [8,9].
DOI 10.1007/978-3-319-04627-3_4
Nevertheless, the majority of depressed young people do not receive any type of treatment
and those treated experience delays in the initiation of treatment. This is especially challenging
as longer duration of untreated illness in children and adolescents has been linked to more
frequent recurrences and greater difficulties with development of social and emotional skills,
leading to poor outcomes [10]. Therefore, early detection and intervention may be essential to
preventing depression-derived psychosocial and emotional sequelae. In this chapter, several
scales that can assist the clinician in screening for depression in children and adolescents, rating
its overall severity, and assessing changes in severity over time will be discussed.
Examples of scales in pediatric depression

The Center for Epidemiological Studies Depression Scale for Children
The Center for Epidemiological Studies Depression Scale for Children (CES-DC) is a 20-item
(empirically selected) self-report depression questionnaire developed for the screening
of depressive symptoms corresponding to different depressive disorders in non-clinical
samples [11,12]. It takes an average of 5 minutes to complete and another 5 minutes to rate.
The CES-DC uses a multidimensional approach to assess depressive symptoms in children
and adolescents 6 to 17 years of age over the past week. It can be used on an individual or
group level.
The items consist of simple statements about emotional, cognitive, and behavioral
components of depressiveness, drafted in first-person style. Most items are rated on a four-point
scale in relation to their incidence during the past week (0 = ‘‘not at all’’; 1 = ‘‘a little’’; 2 = ‘‘some’’;
3 = ‘‘a lot’’). However, items 4, 8, 12, and 16 are phrased positively, and thus are scored in the
opposite order (3 = “not at all”; 2 = “a little”; 1 = “some” ; 0 = “a lot”) [12,13]. The total score is the
sum of all item scores (ranging from 0 to 60), with higher CES-DC scores indicating increasing
levels of depression. A cut-off point of 15 used for the screening of children and adolescents
in clinical settings produced a false-positive rate of 41% and a false negative rate of 37% [13].
Studies in non-clinical samples suggest that a higher cutoff is needed [12,13]. The total score
is unreliable when more than four items are not answered [14]. Factor analyses have revealed
a four-factor structure in the adult version: negative affect, positive affect, somatic, and
interpersonal factors [14]. The same factors have been found in adolescents [15].
The CES-DC showed moderate to high correlation with other depression tests such as the
Children’s Depression Inventory (CDI) (r = 0.44 to r = 0.58) [13,15], but also with depression-like
constructs and total scores for emotional and behavioral problems (r = 0.52 for anxiety; r = 0.43
for self-esteem; r = 0.59 for the total score of the Child Behavior Checklist) [14,15], which is a
limitation for the discriminant validity of the CES-DC. Internal consistency is generally good,
with Cronbach’s α ranging from 0.77 to 0.91, [13,16–18], although lower consistency has
been reported for younger children than for adolescents and for boys than for girls [12,13].
Test–retest reliability has been analyzed showing r = 0.79 for a 1-week interval in a 15-year-old
A ssessment o f Pediatric D epressi o n 37
Guatemalan population [19], and r = 0.51 for a 2-week interval in child and adolescent patients
after discharge [12].
Thus, the CES-DC has moderate-to-good internal reliability and moderate stability in
adolescents, with limited utility in children. Its brevity makes it useful as a first-line screening
instrument, although due to its low discriminant validity, further assessment is required.
Kutcher Adolescent Depression Scale

The Kutcher Adolescent Depression Scale (KADS) is a short self-report scale for both
diagnosing and monitoring the severity of depression in adolescents [20]. There are three
forms of the scale: the 6-item, the 11-item, and the 16-item. In its full form, the KADS consists of
16 items covering the core symptoms of adolescent depression, including cognitive, affective,
behavioral, psychomotor, and somatic fields. Items are described in standard colloquial
language. The scale measures frequency of symptoms over the previous week on a scale from
0 to 3: “hardly ever”; “much of the time”; “most of the time”; and “all of the time.” The total score
is the sum of all 16 items. There are some exceptions to this coding:
•• item 8 (appetite changes) has a dichotomous answer where subjects indicate if their
appetite has increased or decreased (this response does not contribute to the total score);
•• response options for items 12 (interest in/thoughts re: sex, sexual arousal); and
•• item 13 (thoughts/actions regarding suicide/self-harm) are worded slightly differently, but
are also listed in ascending order of morbidity, with four response options required in item
12 (from 0 to 3) and five in item 13 (from 0 to 4).
The diagnostic validity of the KADS has been demonstrated in a school-based sample of
adolescents [20]. The study used receiver operating characteristic curve analysis to compare
the diagnostic validity of the full-length KADS, briefer versions of that scale, and the Beck
Depression Inventory (BDI) against the criteria for a major depressive episode from the Mini
International Neuropsychiatric Interview. The results showed that a 6-item subscale of the
KADS could be used at least as effectively as the BDI to screen for major depressive episodes
among school-based adolescents [20].
To investigate which version of the KADS had optimal sensitivity to change, a subsequent
study compared the 6-item version, a longer 11-item version, and the full 16-item scale against
the clinician-rated Children’s Depression Rating Scale-Revised (CDRS-R) [20]. Clinician-rated
changes in severity were significantly better corroborated by the 11-item KADS (mean correlation
with the CDRS-R, r = 0.69) than by the 6-item KADS (r = 0.62) and at least as well corroborated
as by the full-length KADS (r = 0.64) [21]. Furthermore, in terms of mean percentage change in
scores from day 0 to day 56, the 11-item KADS (59%) significantly outperformed the full-length
KADS (46%) and the CDRS-R (43%) and at least matched the performance of the 6-item KADS
(56%) [21]. Thus, the KADS scale ultimately consists of a package with a 6-item version intended
for screening and a longer version (either 11 or 16 items) intended for evaluative purposes.
Reynolds Child/Adolescent Depression Scale

The Reynolds Child Depression Scale (RCDS) and the Reynolds Adolescent Depression Scale
(RADS) [22,23] are two 30-item self-report questionnaires developed for screening, monitoring,
and measuring the severity of depressive symptomatology in children (ages 9–12) and
adolescents [18–22], respectively. Both instruments are easy to administer and take no longer
than 10 minutes to complete.
Their structures are analogous, using a four-point (1 to 4) response format (“almost never”;
“hardly ever”; “sometimes”; and “most of the time”). The tests contain six critical items that
have been shown to discriminate between depressed and non-depressed individuals. Scores
range between 30 and 120 (the higher the score, the more severe the episode). A healthy
standardization sample was used to validate mean scores between 52 and 60 [22]. Both a
total score of 77 or higher and a score of 3 or 4 on at least four of the six critical items on two
consecutive occasions have been proposed as a threshold for significant depression [24].
The RCDS has been found to have excellent internal consistency and reliability [25].
Convergent validity has been reported for the RCDS when correlated with other measures
of depression, self-esteem, and anxiety [22]. The RADS has also shown excellent internal
reliability and very good stability in young community samples [25,26]. Regarding convergent
validity, the RADS shows a correlation of 0.51 with the suicide-ideation question (“During the
last month have you thought about killing yourself?”), a correlation of 0.55 with the general well-
being question (“In general, how are you feeling?”), and a correlation of –0.63 with the student
happiness question (“Are you feeling happy or satisfied with your life?”) [26]. The RADS has also
been used to examine the effects and the phenomenology of depression, suicidality, violence,
and loss and has served as a model for other depression and suicidality scales.
Despite these advantages, both have some disadvantages derived from their
development and predominant use in non-clinical samples, probably related to their weaker
ability in monitoring clinical changes and treatment effects. Parent and teacher scores do not
agree with child self-ratings. Sensitivity, specificity, and a norm cut-off score in clinical subjects
have also not been developed [26].
There is an abbreviated version of the RADS, the RADS-2: Short Form (RADS-2: SF) [27],
consisting of ten items used to screen for and measure the severity of depressive symptoms in
adolescents 12 to 20 years of age. The RADS-2: SF includes the six critical items from the RADS
and four other items selected to reflect mood disorder, loss of interest, and irritability. It takes
2–3 minutes to complete and can be administered in an individual or group setting, making it a
useful tool for school guidance counselors and psychologists. The RADS-2: SF has been found
to have acceptable reliability and validity and to have psychometric properties comparable to
the RADS in a large population of adolescents [28].
Children’s Depression Rating Scale–Revised

The CDRS-R is a semi-structured clinician-rated interview developed to assess depression in
children 6–12 years of age [29]. It is based on the Hamilton Depression Rating Scale and covers
different symptom domains, assessing physical symptoms more deeply than other scales.
It includes several items not specific to depression, which limits its discriminant validity. The
CDRS-R integrates information from different sources and also takes into account the child´s
behavior during the interview, which allows for a comprehensive assessment. Although a
high degree of clinical expertise is needed for raters, good concordance among examiners
has been reported [26]. The clinician is required to produce three different scores: parent and
child scores, based on individual interviews with each, and a final summary score. There are
17 symptom areas that are assessed: 14 on a seven-point Likert scale and three on a five-point
scale. For the items that use a seven-point scale, a score of 1 or 2 is consistent with subclinical or
no symptoms; a score of 3–4 with clinical symptoms; and a score of 5–7 with severe symptoms.
For the three items using a five-point scale, a score of 4 or 5 is indicative of severe symptoms.
The sum of all 17 items produces the summary score. Scores of ≥40 indicate a high likelihood of
a depressive disorder [30].
Normative data were based on a non-clinical sample of children who were interviewed
directly, showing good internal consistency (Cronbach’s α 0.85), good test-retest reliability
(0.89), and good inter-rater reliability (0.92) [29,30]. Although the instrument was designed
for use in children, good reliability and validity have been demonstrated in adolescents with
depression [31,32]. Internal consistency was good on three consecutive visits (screening: 0.79;
baseline: 0.74; exit: 0.92), and total score correlated highly with global severity (0.87–0.93)
in a clinical sample of adolescents. Reductions in the CDRS-R total score correlated with
improvement scores at exit [31]. In another study conducted with adolescents in primary care
settings, scores of ≥30 on the CDRS-R achieved a sensitivity of 83% and a specificity of 84% [32].
The CDRS-R has been widely used in research due to its clinician-rated format, the
integration of different sources of information, and its usefulness for monitoring treatment
effects. However, rater and time constraints make it less useful in clinical settings.
Featured scale: Children’s Depression Inventory

The CDI is one of the most frequently used scales for the screening of depression in children
and adolescents [26,33]. It is a self-report instrument covering the core symptoms of
depression, based on the BDI, developed for use in children and adolescents between 7 and
17 years of age. Although the CDI was originally created for individual use in clinical settings,
it has been expanded to non-clinical settings and the group format. It is written in colloquial
language and is easy to understand both for children and adolescents.
The CDI is a norm-referenced test, based on clinical samples [33]. It contains 27 items
with three answer options (0: absence of symptoms; 1: mild symptoms; and 2: definite
symptoms) covering a temporal framework of two weeks, and a total score ranging from 0 to
54. Following a five-factor solution for children and adolescents, the full-length CDI is divided
into five subscales: negative mood, interpersonal problems, ineffectiveness, anhedonia, and
negative self-esteem, although a general score is preferred [26]. While a cut-off score of 19 was
recommended for authors in non-clinical populations, lower scores have been proposed in
clinical samples; recently, a study including children and adolescents found that a cut-off of 16
correctly classified patients with depression, with a sensitivity of 94% and a specificity of 84%
[34]. The CDI can also be used as a continuous measure of depressive symptoms, as it has well-
established sensitivity to change [35]. Along with the full scale, a short form including 12 items
is also available. Parent-rated (17 items) and teacher-rated (12 items) versions have also been
developed. Items on both scales are rated from 0 to 3 in order to gather a more comprehensive
assessment and are rephrased to emphasize symptoms of depression most likely to be
observed.
Regarding psychometric properties, internal consistency evaluated with Cronbach’s
α ranges from 0.71 to 0.87 [34–36]. Test-retest reliability is highly variable, depending on the
time interval between assessments, and is lower in the general population than in clinical
samples [37,38]. However, a recent study found good correlation when used 6-months apart
(r = 0.73 for children and r= 0.72 for adolescents) [39]. Regarding concurrent validity, the CDI
was found to correlate positively with scales measuring anxiety, self-esteem, or hopelessness,
and to predict risk of future depression [40]. As for discriminant validity, results were better with
semi-structured diagnostic interviews than with clinically-derived diagnosis [41]. Using the CDI
with the CDRS-R seems to provide a more accurate diagnostic assessment [28].
A meta-analysis exploring gender and ethnic considerations related to the CDI pointed to an
age-by-gender interaction, stressing that boys tend to have higher depression scores at younger
ages, while girls’ scores are slightly higher in pre-adolescence [42]. Results for ethnic differences
were mixed [42]. The CDI is available in 43 languages, although relatively few studies have been
performed to validate the translated versions [34]. A Spanish version of the CDI is available for
Spanish-speaking populations. The second edition, CDI-2, has been available since 2011 [43].
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Inc; 2011.
5. Assessment scales for geriatric
patients
George S. Alexopoulos
General aspects of depression scales for geriatric patients

Late-life depression causes suffering, family disruption, and disability, worsens the outcomes
of many medical illnesses, and increases mortality [1]. Depression preferentially afflicts older
adults with cognitive impairment and high medical burden [2]. Part of the reason is that
vulnerability to late-life depression is principally caused by aging-related and disease-related
processes, including arteriosclerosis, inflammatory, endocrine, and immune changes that
compromise the integrity of frontolimbic pathways [1]. Heredity is an additional vulnerability
factor. Chronic stress resulting from financial difficulties, disability, isolation, relocation,
caregiving, and bereavement, causes physiological changes, which further increase
vulnerability to depression or trigger depression in already vulnerable older adults.
Symptom assessment
Cognitive impairment is ubiquitous in late-life depression. Approximately 20% of older adults
with dementia also have major depression, and an additional 15% have milder depressive
syndromes. Depression is often a prodrome and a risk factor for dementia [3,4]. Even older
patients with major depression, but without dementia, often experience disturbances in
attention, speed of mental processing, and executive function [5]. These deficits improve
after remission of late-life major depression but still remain abnormal [6,7]. In some older
patients with depression, cognitive dysfunction can be severe enough to meet the
criteria for dementia, but subsides when the symptoms and signs of depression remit. This
‘reversible’ dementia syndrome is usually mild and occurs in the context of severe late-onset
depression [8]. More than 40% of depressed older patients with reversible dementia develop
an irreversible dementia syndrome during follow-up, suggesting that the pathophysiological
changes of depression unmask a subclinical dementia process (ie, depression uncovered the
patients’ decreased reserve cognitive capacity) [8]. Patients with depression who do not go on
DOI 10.1007/978-3-319-04627-3_5
to develop dementia may have a non-progressive brain lesion compromising circuitry related
to mood and cognitive symptoms. Another possibility is that their cognitive dysfunction is an
integral part of severe geriatric depression because cognitive dysfunction can be a primary
sign of depression rather than an indirect behavioral consequence of the affective symptoms
of depression. The frequent presence of depression in patients with reversible or irreversible
dementia underscores the need for a reliable assessment method of depression in this
population.
Various factors complicate the assessment of depression in patients with cognitive
impairment or dementia. Some symptoms of depression overlap with behavioral
manifestations of dementia, including apathy and loss of initiative. In patients with dementia,
depressive symptoms may fluctuate over time or fail to meet criteria for intensity, duration, or
functional impact required for a diagnosis of major depression. The clinical presentation of
depressive symptoms and signs may change with the progression of Alzheimer’s disease [9].
Another problem in ascertaining depressive symptoms is the difficulty of cognitively
impaired and patients with dementia to accurately report depressive symptoms. In fact, the
identification of depressive symptomatology in patients with dementia varies markedly
depending on whether it is based on reports from patients, caregivers, or trained observers
[10–12]. Sampling from psychiatric settings is likely to result in higher rates of depression than in
population-based samples of patients with dementia. As a result, the prevalence of depressive
disorders in patients with dementia ranges from 0–87% [13]. Patient inability to communicate
coherently may increase reliance on behavior alone in assessing depression. Combining a
patient interview with information obtained by caregivers and using depression scales that
focus on symptoms not shared by the depression and the dementia syndromes is helpful in
assessing depressive symptoms and signs of older adults with varying degrees of cognitive
dysfunction [10].
Examples of observer rating scales for geriatric patients

Self-rated scales
The Beck Depression Inventory (BDI) and the Zung Self-Rating Depression Scale have
been used in cognitively unimpaired subjects and those with mild dementia [14–17]. The
BDI correlated well with scores on the Hamilton Depression Rating Scale (HAM-D) in both
unaffected patients and patients with mild dementia [16]. However, 23% of subjects with mild
dementia may be unable to complete the Zung Self-Rating Depression Scale [17].
The Geriatric Depression Scale (GDS) was developed with the goal to discriminate
depressive symptoms from complaints often reported by non-depressed older adults [18].
The GDS does not assess vegetative symptoms of depression because some such symptoms
often occur in normal elders. The GDS consists of 30 questions. An abbreviated 15-item scale
A ssessment scales fo r geriatric patients 45
also exists. The “yes/no” question format makes the GDS accessible to the elderly population.
Although the GDS was originally designed as a self-administered test, it can also be used in a
rater-administered format and by telephone [19].
The GDS was initially validated in depression and among normal older adults living in
the community [18]. A cut-off score of 11 on the GDS identifies late-life depression with a
sensitivity of 84% and a 95% specificity rate, while a cut-off score of 14 has a sensitivity of 80%
and a specificity of 100% [18]. The GDS has been validated in diverse older populations. It has an
acceptable performance in older medical patients [20,21]. The GDS is an accurate screening test
for depression in cognitively intact elderly outpatients, but may not perform well in populations
that include large numbers of cognitively impaired patients [22,23]. Approximately 50% of
nursing home residents are unable to rate the GDS mainly because of cognitive impairment
[24,25]. In institutionalized patients, a GDS cut-off score of 13 was only 47% sensitive and 75%
specific in screening for depression [26]. Another study of nursing home residents showed
that a GDS cut-off score of 10 or greater identified depression with a sensitivity of 63% and a
specificity of 83% [27]. When those with a mini-mental state examination (MMSE) score greater
or equal to 15 were included, the sensitivity and specificity of GDS improved to 84% and 91%,
respectively. Worse memory was associated with more self-reported depressive symptoms [28].
Alzheimer patients who disavow cognitive deficits also tend to disavow depressive symptoms.
These observations suggest that the performance of GDS may be influenced both by memory
impairment and by patients’ inability to identify their cognitive impairment. In sum, the GDS-30
is a reliable screening tool for depressive symptoms in patients without dementia and with mild
cognitive impairment, but not in patients with moderate or severe dementia [29–31].
Interviewer-rated scales
Scales such as the HAM-D and the Montgomery-Åsberg Depression Rating Scale (MADRS)
are broadly used to quantify severity of depression. Potential limitations of the HAM-D are
its scoring system that mixes frequency and severity of symptoms, its heterogeneous factor
structure, and its emphasis on somatic symptoms that are common even in non-depressed
older adults. The HAM-D utilizes information from a patient interview and requires sufficient
comprehension and judgment to answer questions related to affect and ideation. Further,
valid information about sleep, eating, and other physiological functions can be obtained only
from patients with intact memory. Thus, patients with moderate or severe dementia cannot
be reliably evaluated on the basis of information derived solely from a HAM-D structured
interview. The HAM-D has been inadequately validated in older adults [32].
The MADRS consists of ten items, each rated across six grades. The MADRS does not include
somatic items likely to be endorsed by non-depressed older adults. The MADRS has been
validated in younger populations and its performance compared against other rating scales [33].
However, its non-somatic items require accurate understanding and rather complex judgments
that may be difficult to be made by patients with dementia. Nonetheless, there is evidence that
the MADRS may correctly identify depression in outpatients of a memory clinic and in patients
with dementia when administered to patients’ caregivers [34–36].
The Alzheimer’s Disease Assessment Scale

The Alzheimer’s Disease Assessment Scale (ADAS) was specifically designed for the assessment of
patients with Alzheimer’s disease [37]. It consists of a cognitive component and a non-cognitive
component. The non-cognitive behavioral component of ADAS consists of clinician ratings of:
• depression;
• tearfulness;
• restlessness;
• appetite;
• hallucinations;
• delusions;
• pacing;
• concentration; and
• tremor.
It is scored on the basis of patient observation and an interview of an informant. While it circumvents
most of the difficulties associated with interview scales, the behavior component of ADAS includes
only a small number of depressive signs and symptoms and may, therefore, be insensitive in detecting
mild depression. Moreover, the ADAS was developed primarily for assessment of patients with
moderate or severe dementia whose cognitive impairments were expected to be progressive ; thus,
it may be less useful in evaluating depressive symptoms in patients with mild dementia or in patients
whose cognitive functioning improves.
Depression Signs Scale

This rating scale consists of nine items whose ratings are based exclusively on patient
observation [38]. The Depression Signs Scale (DSS) has satisfactory inter-rater reliability, but
its internal consistency and validity require further testing. The DSS can be useful for rating
depression in subjects with severe dementia. However, this instrument may be less suitable
for assessing depression in patients with mild or moderate dementia, as it covers a relatively
narrow range of depressive manifestations and does not include items that require interaction
with the subject. Therefore, the DSS may fail to assess important aspects of the depressive
syndrome in patients with mild depression.
Neuropsychiatric Inventory
The Neuropsychiatric Inventory (NPI) was developed to assess ten behavioral domains often
disturbed in patients with dementia [39], such as:
• delusions;
• hallucinations;
• dysphoria;
• anxiety;
• agitation/aggression;
• euphoria;
• disinhibition;
• rritability/lability;
• apathy; and
• aberrant motor behavior.
The NPI is a rater-administrated instrument based on structured interview of the patient’s
caregiver. The assessment of each domain starts with a gateway question. If the response to
the gateway question is affirmative, the rater asks seven to nine follow-up questions on specific
symptoms (part of this domain). Any endorsed symptom is rated on a four-point frequency
scale as well as a three-point severity scale. The total subscale score is the product of frequency
and severity scores.
A major asset of the NPI is its brevity. However, the cost of brevity is a less complete
assessment of the depressive syndrome. Further, some depressive symptoms may be
missed, especially when the gateway questions are answered negatively. To overcome these
limitations the Neuropsychiatric Inventory-Clinician Rating Scale (NPI-C) has been developed,
which expands the NPI domains and items and relies on a clinician-rating methodology [40].
The convergent validity of the NPI-C was tested against the Cornell Scale for Depression in
Dementia (CSDD) and found to be satisfactory (r=0.61).
Dementia Mood Assessment Scale

The Dementia Mood Assessment Scale (DMAS) is a 24-item scale that assesses observable
mood functional capacities of patients with dementia [41]. Some of the DMAS items are
derived from HAM-D but its items were formulated in a way that they can be assessed
objectively. The first 17 items are the most representative of mood symptoms and signs in
dementia. The remaining seven items are related to the severity of dementia but are not
intended to assess mood per se. The initial validation of DMAS was based on a semi-structured
patient interview and patient observation through a one-way mirror. The 17-item dementia
mood scale was not influenced by global functional or cognitive impairment, suggesting that
this subscale does not simply reflect severity of dementia. In contrast, the last seven items of
the DMAS were correlated with global impairment scores.
Featured scale: Cornell Scale for Depression in Dementia

The CSDD is a 19-item instrument specifically designed for the rating of symptoms and
signs of depression in patients with dementia [10,42] (Appendix D). The items were selected
after reviewing the literature on the phenomenology of depression in patients with [37,43]
and without [44] dementia, and obtaining information from a questionnaire answered by 11
geriatric psychiatrists from the Cornell University Medical College and other experts in the
field. Items were constructed so that they could be rated primarily on the basis of observation.
Phobias, obsessions, and complex depressive ideation were not included in the scale because
they usually require reliable self-reporting. To simplify the use of the scale, the severity of
each item is rated according to three explicitly defined grades (ie, absent, mild/intermittent,
and severe).
How to use the Cornell Scale for Depression in Dementia

The CSDD is administered in two steps: the clinician interviews the patient’s caregiver on each
of the 19 items of the CSDD and then briefly interviews the patient. The interview is guided
by a detailed Administration Manual that describes each item and guides the interviewer
(Appendix D). The clinician is free to use additional descriptions to help the caregiver
understand the meaning of each item. The caregiver is instructed to base his/her report on
observations of the patient’s behavior during the week prior to interview.
Two of the items, “loss of interest” and “lack of energy,” require not only that the patient
is less involved in usual activities or has less energy during the week prior to interview, but
also that changes in these behaviors occurred relatively acutely (ie, over a period of less than
1 month). In these two items, the caregiver is initially asked to describe the patient’s behavior
during the week prior to interview and, then, is asked to provide information about the onset of
behavioral changes that may have occurred earlier. The item on weight loss is based entirely on
information about the patient’s weight during the month preceding the interview.
During the interview with the caregiver, the clinician assigns preliminary scores to
each item of the CSDD. Next, the clinician briefly interviews the patient using CSDD items
as a basis for inquiry and observation, but does not necessarily confine himself/herself to
these questions. If there is a large discrepancy between the clinician’s observations and the
caregiver’s report on any item, the clinician interviews the caregiver and/or the patient again
and attempts to clarify the reason for disagreement. After this process, the CSDD is scored on
the basis of the clinician’s final judgment.
Quality and characteristics of the Cornell Scale for Depression in Dementia

The CSDD was initially validated in elderly patients (with and without dementia) [10,42]. In more
recent studies, the CSDD performed well in distinguishing depressed from non-depressed
long-term care patients [35]. The CSDD consistently identified depression in outpatients with
Alzheimer’s dementia and found to be a valid screening tool for depression in older adults with
and without dementia [30,34]. CSDD scores at baseline was a risk factor for later development
of depression in long-term care facilities [45]. The CSDD has been found sensitive to change
with treatment [46]. In outpatients with probable Alzheimer’s disease, principal-factors analysis
of the CSDD identified four factors [47]:
•• general depression (lack of reactivity to pleasant events, poor self-esteem, pessimism, loss
of interest, physical complaints, psychomotor retardation, sadness);

•• rhythm disturbances (difficulty falling asleep, multiple night awakenings, early morning
awakenings, weight loss, diurnal variation of mood);
•• agitation/psychosis (agitation, mood-congruent delusions, suicide); and
•• negative symptoms (appetite loss, weight loss, lack of energy, loss of interest, lack of
reactivity to pleasant events).
Receiver-operated characteristics analyses showed that a cut-off score greater than 7 might
be optimal in distinguishing depressed from non-depressed patients with dementia [48].
More than 30% of long-term care patients had a CSDD score >7 [49]. However, the cut-off score
associated with depression may be influenced by cultural factors; for example, a higher cut-off
score distinguished depressed from non-depressed older patients more often in Brazilian than
in Norwegian samples [50,51].
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45 McCusker J, Cole MG, Voyer P, et al. Observer rated depression in long-term care: Frequency and risk
factors. Arch Gerontol Geriatr. 2013;pii: S0167-4943.
46 Cummings J, Mega M, Gray K, et al. Neuropsychiatric Inventory. In: Rush AJ, ed. Handbook of Psychiatric
Measures. Washington, DC: American Psychiatric Association; 2000:405-407.
47 Harwood DG, Ownby RL, Barker WW, Duara R. The factor structure of the Cornell Scale for Depression in
Dementia among probable Alzheimer’s disease patients. Am J Geriatr Psychiatry. 1998;6:212-220.
48 Vida S, Des Rosiers P, Carrier L, Gauthier S. Depression in Alzheimer’s disease: receiver operating
characteristic analysis of the Cornell Scale for Depression in Dementia and the Hamilton Depression
Scale. J Geriatr Psychiatry Neurol. 1994;7:159-162.
49 Iden KR, Engedal K, Hjorleifsson S, Ruths S. Prevalence of depression among recently admitted long-
term care patients in Norwegian nursing homes: associations with diagnostic workup and use of
antidepressants. Dement Geriatr Cogn Disord. 2013;37:154-162.
50 Knapskog AB, Portugal Mda G, Barca ML, et al. A cross-cultural comparison of the phenotype of
depression as measured by the Cornell Scale and the MADRS in two elderly outpatient populations.
51 Portugal Mda G, Coutinho ES, Almeida C, et al. Validation of Montgomery-Asberg Rating Scale and Cornell
Scale for Depression in Dementia in Brazilian elderly patients. Int Psychogeriatr. 2012;24:1291-1298.
Appendix A
Hamilton Depression Rating Scale, 21-item version
Hamilton Depression Rating Scale (HAM-D), 21-item version
1. Depressed Mood (sadness, hopeless, helpless, worthless)

Absent 0
These feeling states indicated only on questioning 1
These feeling states spontaneously reported verbally 2
Communicates feeling states non-verbally – ie, through facial expression, posture, voice, and 3
tendency to weep
Patient reports VIRTUALLY ONLY these feeling states in his spontaneous verbal and non-verbal 4
communication
2. Feelings of Guilt
Absent 0
Self-reproach, feels he has let people down 1
Ideas of guilt or rumination over past errors or sinful deeds 2
Present illness is a punishment. Delusions of guilt 3
Hears accusatory or denunciatory voices and/or experiences threatening visual hallucinations 4
3. Suicide
Absent 0
Feels life is not worth living 1
Wishes he were dead or any thoughts of possible death to self 2
Suicidal ideas or gesture 3
Attempts at suicide (any serious attempt rates 4) 4
Hamilton Depression Rating Scale (HAM-D), 21-item version (continued overleaf)

DOI 10.1007/978-3-319-04627-3
Hamilton Depression Rating Scale (HAM-D), 21-item version (continued)
4. Insomnia Early
No difficulty falling asleep 0
Complains of occasional difficulty falling asleep – ie, more than 1/2 hour 1
Complains of nightly difficulty falling asleep 2
5. Insomnia Middle
No difficulty 0
Patient complains of being restless and disturbed during the night 1
Waking during the night – any getting out of bed rates 2 (except for purposes of voiding) 2
6. Insomnia Late
No difficulty 0
Waking in early hours of the morning but goes back to sleep 1
Unable to fall asleep again if he gets out of bed 2
7. Work and Activities
No difficulty 0
Thoughts and feelings of incapacity, fatigue or weakness related to activities, work or hobbies 1
Loss of interest in activity, hobbies or work – either directly reported by patient, or indirect in 2
listlessness, indecision and vacillation (feels he has to push self to work or activities)
Decrease in actual time spent in activities or decrease in productivity 3
Stopped working because of present illness 4
8. Retardation: Psychomotor
(slowness of thought and speech; impaired ability to concentrate; decreased motor activity)
Normal speech and thought 0
Slight retardation at interview 1
Obvious retardation at interview 2
Interview difficult 3
Complete stupor 4
9. Agitation
None 0
Fidgetiness 1
Playing with hands, hair, etc 2
Moving about, can’t sit still 3
Hand wringing, nail biting, hair-pulling, biting of lips 4
Hamilton Depression Rating Scale (HAM-D), 21-item version (continued opposite)
A ppendix a 55
10. Anxiety (psychological)

No difficulty 0
Subjective tension and irritability 1
Worrying about minor matters 2
Apprehensive attitude apparent in face or speech 3
Fears expressed without questioning 4
11. Anxiety Somatic: Physiological concomitants of anxiety (effects of autonomic
overactivity, “butterflies,” indigestion, stomach cramps, belching, diarrhea, palpitations,
hyperventilation, paresthesia, sweating, flushing, tremor, headache, urinary frequency).
Avoid asking about possible medication side effects (ie, dry mouth, constipation)
Absent 0
Mild 1
Moderate 2
Severe 3
Incapacitating 4
12. Somatic Symptoms (gastrointestinal)
None 0
Loss of appetite but eating without encouragement from others. Food intake about normal 1
Difficulty eating without urging from others. Marked reduction of appetite and food intake 2
13. Somatic Symptoms General
None 0
Heaviness in limbs, back or head. Backache, headache, or muscle aches. Loss of energy and 1
fatigability
Any clear-cut symptom rates “2” 2
14. Genital Symptoms (symptoms such as loss of libido; impaired sexual performance; menstrual
disturbances)
Absent 0
Mild 1
Severe 2
15. Hypochondriasis
Not present 0
Self-absorption (bodily) 1
Preoccupation with health 2
Frequent complaints, requests for help 3
Hypochondriacal delusions 4
Hamilton Depression Rating Scale (HAM-D), 21-item version (continued overleaf)
16. Loss of weight

No weight loss 0
Probable weight loss associated with present illness 1
Definite (according to patient) weight loss 2
Not assessed 3
17. Insight
Acknowledges being depressed and ill 0
Acknowledges illness but attributes cause to bad food, climate, overwork, virus, need for rest 1
Denies being ill at all 3
18. Diurnal variation
Note whether symptoms are worse in morning or evening. If no diurnal variation, mark 0
No variation 0
Worse in AM 1
Worse in PM 2
When present, mark the severity of the variation. Mark “None” if no variation
None 0
Mild 1
Severe 2
19. Depersonalization and derealisation (eg, feelings of unreality, nihilistic ideas)
Absent 0
Mild 1
Moderate 2
Severe 3
Incapacitating 4
20. Paranoid symptoms
None 0
Suspicious 1
Ideas of reference 2
Delusions of reference and persecution 3
21. Obsessional and compulsive symptoms
Absent 0
Mild 1
Severe 2
Hamilton Depression Rating Scale (HAM-D), 21-item version. Reproduced with permission from
Hamilton M. A rating scale for depression. J Neurol Neurosurg Psychiatry. 1960;23:56-62 ©BMJ.
Appendix B
Montgomery-Åsberg Depression Rating Scale

The rating should be based on a clinical interview moving from broadly phrased questions
about symptoms to more detailed ones which allow a precise rating of severity. The rater must
decide whether the rating lies on the defined scale steps (0, 2, 4, 6) or between them (1, 3, 5).
It is important to remember that it is only on rare occasions that a depressed patient
is encountered who cannot be rated on the items in the scale. If definite answers cannot be
elicited from the patient, all relevant clues and information from other sources should be used
as a basis for the rating, in line with customary clinical practice.
Montgomery-Åsberg Depression Rating Scale
1. Apparent Sadness
Representing despondency, gloom and despair (more than just ordinary transient low spirits)
reflected in speech, facial expression, and posture. Rate by depth and inability to brighten up
0 No sadness
1
2 Looks dispirited but does brighten up without difficulty
3
4 Appears sad and unhappy most of the time
5
6 Looks miserable all the time. Extremely despondent
2. Reported Sadness
Representing reports of depressed mood, regardless of whether it is reflected in appearance or
not. Includes low spirits, despondency or the feeling of being beyond help and without hope
0 Occasional sadness in keeping with the circumstances
1
Montgomery-Åsberg Depression Rating Scale (continued overleaf)

DOI 10.1007/978-3-319-04627-3
Montgomery-Åsberg Depression Rating Scale (continued)
2 Sad or low but brightens up without difficulty

3
4 Pervasive feelings of sadness or gloominess. The mood is still influenced by external
circumstances
5
6 Continuous or unvarying sadness, misery or despondency
3. Inner Tension
Representing feelings of ill-defined discomfort, edginess, inner turmoil, mental tension
mounting to either panic, dread or anguish. Rate according to intensity, frequency, duration
and the extent of reassurance called for
0 Placid. Only fleeting inner tension
1
2 Occasional feelings of edginess and ill-defined discomfort
3
4 Continuous feelings of inner tension or intermittent panic which the patient can only master
with some difficulty
5
6 Unrelenting dread or anguish. Overwhelming panic
4. Reduced Sleep
Representing the experience of reduced duration or depth of sleep compared to the subject’s
own normal pattern when well
0 Sleeps as normal.
1
2 Slight difficulty dropping off to sleep or slightly reduced, light, or fitful sleep
3
4 Moderate stiffness and resistance
5
6 Sleep reduced or broken by at least 2 hours
5. Reduced Appetite
Representing the feeling of a loss of appetite compared with when well. Rate by loss of desire
for food or the need to force oneself to eat
0 Normal or increased appetite
1
2 Slightly reduced appetite
3
Montgomery-Åsberg Depression Rating Scale (continued opposite)
A ppendix B 59
4 No appetite. Food is tasteless

5
6 Needs persuasion to eat at all
6. Concentration Difficulties
Representing difficulties in collecting one’s thoughts mounting to an incapacitating lack of
concentration
0 No difficulties in concentrating
1
2 Occasional difficulties in collecting one’s thoughts
3
4 Difficulties in concentrating and sustaining thought which reduced ability to read or hold a
conversation
5
6 Unable to read or converse without great difficulty
7. Lassitude
Representing difficulty in getting started or slowness in initiating and performing everyday
activities
0 Hardly any difficulty in getting started. No sluggishness
1
2 Difficulties in starting activities
3
4 Difficulties in starting simple routine activities which are carried out with effort
5
6 Complete lassitude. Unable to do anything without help
8. Inability to Feel
Representing the subjective experience of reduced interest in the surroundings or activities
that normally give pleasure. The ability to react with adequate emotion to circumstances or
people is reduced
0 Normal interest in the surroundings and in other people
1
2 Reduced ability to enjoy usual interests
3
4 Loss of interest in the surroundings. Loss of feelings for friends and acquaintances
5
6 The experience of being emotionally paralyzed, inability to feel anger, grief or pleasure and a
complete or even painful failure to feel for close relatives and friends
Montgomery-Åsberg Depression Rating Scale (continued overleaf)
9. Pessimistic Thoughts
Representing thoughts of guilt, inferiority, self-reproach, sinfulness, remorse, and ruin
0 No pessimistic thoughts
1
2 Fluctuating ideas of failure, self-reproach or self-depreciation
3
4 Persistent self-accusations or definite but still rational ideas of guilt or sin. Increasingly
pessimistic about the future
5
6 Delusions of ruin, remorse, or irredeemable sin. Self-accusations which are absurd and
unshakable
10. Suicidal Thoughts
Representing the feeling that life is not worth living, that a natural death would be welcome,
suicidal thoughts, and preparations for suicide. Suicide attempts should not in themselves
influence the rating
0 Enjoys life or takes it as it comes
1
2 Weary of life. Only fleeting suicidal thoughts
3
4 Probably better off dead. Suicidal thoughts are common, and suicide is considered as a
possible solution, but without specific plans or intentions
5
6 Explicit plans for suicide when there is an opportunity. Active preparations for suicide
Montgomery-Åsberg Depression Rating Scale. Reproduced with permission from Montgomery SA,
Åsberg M. A new depression scale designed to be sensitive to change. Br J Psychiatry. 1979;134:382-389
©Royal College of Psychiatrists.
Appendix C
The Hospital Anxiety and Depression Scale

The Hospital Anxiety and Depression Scale
A I feel tense or ‘wound up’:

3 Most of the time
2 A lot of the time
1 From time to time, occasionally
0 Not at all
D I still enjoy the things I used to enjoy:
0 Definitely as much
1 Not quite so much
2 Only a little
3 Hardly at all
A I get a sort of frightened feeling as if something awful is about to happen:
3 Very definitely and quite badly
2 Yes, but not too badly
1 A little, but it doesn’t worry me
0 Not at all
D I can laugh and see the funny side of things:
0 As much as I always could
1 Not quite so much now
2 Definitely not so much now
3 Not at all
The Hospital Anxiety and Depression Scale (continued overleaf)

DOI 10.1007/978-3-319-04627-3
The Hospital Anxiety and Depression Scale (continued)
A Worrying thoughts go through my mind:

3 A great deal of the time
2 A lot of the time
1 From time to time but not too often
0 Only occasionally
D I feel cheerful:
3 Not at all
2 Not often
1 Sometimes
0 Most of the time
A I can sit at ease and feel relaxed:
0 Definitely
1 Usually
2 Not often
3 Not at all
D I feel as if I am slowed down:
3 Nearly all the time
2 Very often
1 Sometimes
0 Not at all
A I get a sort of frightened feeling like ‘butterflies’ in the stomach:
0 Not at all
1 Occasionally
2 Quite often
3 Very often
D I have lost interest in my appearance:
3 Definitely
2 I don’t take so much care as I should
1 I may not take quite as much care
0 I take just as much care as ever
The Hospital Anxiety and Depression Scale (continued opposite)
A ppendix c 63
The Hospital Anxiety and Depression Scale (continued)
A I feel restless as if I have to be on the move:

3 Very much indeed
2 Quite a lot
1 Not very much
0 Not at all
D I look forward with enjoyment to things:
0 As much as ever I did
1 Rather less than I used to
2 Definitely less than I used to
3 Hardly at all
A I get sudden feelings of panic:
3 Very often indeed
2 Quite often
1 Not very often
0 Not at all
D I can enjoy a good book or radio or TV programme:
0 Often
1 Sometimes
2 Not often
3 Very seldom
Now check you have answered all questions
FOR HOSPITAL USE ONLY
D (8-10) _____________
A (8-10) _____________
The Hospital Anxiety and Depression Scale. Instructions: Doctors are aware that emotions play an
important part in most illnesses. If your doctor knows about these feelings he will be able to help you more.
This questionnaire is designed to help your doctor to know how you feel. Ignore the numbers printed on the
left of the questionnaire. Read each item and underline the reply which comes closest to how you have been
feeling in the past week. Don’t take too long over your replies; your immediate reaction to each item will
probably be more accurate than a long thought out response. Reproduced with permission from Zigmond
AS, Snaith RP. The hospital anxiety and depression scale. Acta Psychiatr Scand. 1983;67:361-370 ©Wiley.
Appendix D
The Cornell Scale for Depression in Dementia

The Cornell Scale for Depression in Dementia
A. Mood-related symptoms Informant Patient Rater’s Opinion

1. Anxiety 0 1 2 0 1 2 0 1 2
Anxious expression, ruminations, worrying
2. Sadness 0 1 2 0 1 2 0 1 2
Sad expression, sad voice, tearfulness
3. Lack of reactivity to pleasant events 0 1 2 0 1 2 0 1 2
4. Irritability 0 1 2 0 1 2 0 1 2
Easily annoyed, short tempered
B. Behavioral disturbance
5. Agitation 0 1 2 0 1 2 0 1 2
Restlessness, handwringing, hair pulling
6. Retardation 0 1 2 0 1 2 0 1 2
Slow movements, slow speech, slow
reactions
7. Multiple physical complaints 0 1 2 0 1 2 0 1 2
(score 0 if GI symptoms only)
8. Loss of interest 0 1 2 0 1 2 0 1 2
Less involved in usual activities (score only
if change occurred acutely; ie, in less than
1 month)
C. Physical signs
9. Appetite loss 0 1 2 0 1 2 0 1 2
Eating less than usual
The Cornell Scale for Depression in Dementia (continued overleaf)

DOI 10.1007/978-3-319-04627-3
The Cornell Scale for Depression in Dementia (continued)
Informant Patient Rater’s Opinion

10. Weight loss 0 1 2 0 1 2 0 1 2
(score 2 if greater than 5 lbs in 1 month)
11. Lack of energy 0 1 2 0 1 2 0 1 2
Fatigues easily, unable to sustain activities
(score only if change occurred acutely; ie, in
less than 1 month)
D. Cyclic functions
12. Diurnal varation of mood 0 1 2 0 1 2 0 1 2
Symptoms worse in the morning
13. Difficulty falling asleep 0 1 2 0 1 2 0 1 2
Later than usual for this individual
14. Multiple awakenings during sleep 0 1 2 0 1 2 0 1 2
15. Early morning awakening 0 1 2 0 1 2 0 1 2
Earlier than usual for this individual
E. Ideation disturbance
16. Suicide 0 1 2 0 1 2 0 1 2
Feels life is not worth living, has suicidal
wishes, or make suicide attempt
17. Self-deprecation 0 1 2 0 1 2 0 1 2
Self-blame, poor self-esteem, feelings of
failure
18. Pessimism 0 1 2 0 1 2 0 1 2
Anticipation of the worst
19. Mood congruent delusions 0 1 2 0 1 2 0 1 2
Delusions of poverty, illness, or loss
Total score:
Reproduced with permission from Alexopoulos G et al [1] ©Elsevier.
The Cornell Scale for Depression in Dementia Guidelines
Administration and scoring

The Cornell Scale for Depression in Dementia (CSDD) was specifically developed to assess
signs and symptoms of major depression in demented patients. Because some of these
patients may give unreliable reports, the CSDD uses a comprehensive interviewing approach
that derives information from the patient and the informant. Information is elicited through
A ppendix D 67
two semi-structured interviews; an interview of an informant and an interview of the patient.

The interviewer should assign preliminary scores to each item of the scale on the basis of the
informant’s report in the “Informant” column. The next step is for the rater to interview the
patient using the Cornell scale items as a guide. The interviews focus on depressive symptoms
and signs occurring during the week preceding the interview. Many of the items during the
patient interview can be filled after direct observation of the patient. If there are discrepancies
in ratings from the informant and the patient interviews, the rater should re-interview both the
informant and the patient with the goal to resolve the discrepancies. The final ratings of the
CSDD items represent the rater’s clinical impression rather than the responses of the informant
or the patient. The CSDD takes approximately 20 minutes to administer.
Each item is rated for severity on a scale of 0–2 (0=absent, 1=mild or intermittent,
2=severe). The item scores are added. Scores above 10 indicate a probable major depression.
Scores above 18 indicate a definite major depression. Scores below 6 as a rule are associated
with absence of significant depressive symptoms.
Interview with the informant

Who qualifies as an Informant? Informants should know and have frequent contact with the
patient. Reliable informants can include nursing staff for patients in the hospital and nursing
homes or a family member for outpatients.
The informant interview should be conducted first. The interviewer should ask about any
change in symptoms of depression over the previous week. The rater should complete each
item on the scale. The rater can expand on the descriptions of the symptoms in order to help
the informant understand each item.
For the following questions, please refer to how your relative has been feeling during
the past week. Two items, item 8 (“loss of interest”) and item 11 (“lack of energy”), require
both: 1) a disturbance occurring during the week prior to the interview; and 2) changes in
these areas have been occurring over less than one month. In these two items, the caregiver
is instructed to report on the patient’s behavior during the week prior to the interview and
then to give the history of the onset of changes in these two areas that may have taken place
at an earlier time.
A. Mood-Related Signs
1. Anxiety: (anxious expression, ruminations, worrying) Has your relative been feeling anxious
this past week? Has s/he been worrying about things s/he may not ordinarily worry about, or
ruminating over things that may not be that important? Has your relative had an anxious, tense,
distressed or apprehensive expression?
2. Sadness: (sad expression, sad voice, tearfulness) Has your relative been feeling down, sad, or
blue this past week? Has s/he been crying at all? How many days out of the past week has s/he
been feeling like this? For how long each day?
3. Lack of reactivity to pleasant events: If a pleasant event were to occur today (ie, going
out with spouse, friends, seeing grandchildren), would your relative be able to enjoy it fully,
or might his/her mood get in the way of his/her interest in the event or activity? Does your
relative’s mood affect any of the following:
•• his/her ability to enjoy activities that used to give him/her pleasure?
•• his/her surroundings?
•• his/her feelings for family and friends?
4. Irritability: (easily annoyed, short-tempered) Has your relative felt short-tempered or easily
annoyed this past week? Has s/he been feeling irritable, impatient, or angry this week?
B. Behavioral Disturbance
5. Agitation: (restlessness, hand-wringing, hair-pulling) Has your relative been fidgety or restless
this past week that s/he was unable to sit still for at least an hour?
Was your relative so physically agitated that you or others noticed it? Agitation may include
such behaviors as playing with one’s hands, hair, hand-wringing, hair-pulling, and/or lip-biting:
Have you observed any such behavior in your relative during the past week?
6. Retardation: (slow movements, slow speech, slow reactions) Has your relative been talking or
moving more slowly than is normal for him/her? This may include:
•• slowness of thoughts and speech
•• delayed response to your questions
•• decreased motor activity and/or reactions
7. Multiple physical complaints: In the past week, has your relative had any of the following
physical symptoms? (in excess of what is normal for him/her):
•• indigestion?
•• constipation?
•• diarrhea?
•• stomach cramps?
•• belching?
•• heart palpitations?
•• headaches?
•• muscles aches?
•• joint pain?
•• backache?
•• hyperventilation (shortness of breath)?
•• frequent urinations?
•• sweating?
If yes to any of the above, how much have these things been bothering your relative? How bad
have they become and how often have they occurred in the past week? Do not rate symptoms
that are side effects from taking medications or those that are only related to GI ailments.
A ppendix D 69
8. Loss of interest: (less involved in usual activities – score only if change occurred acutely, or in
less than one month) How has your relative been spending his/her time this past week (not
including work and chores)? Has your relative felt interested in his/her usual activities and
hobbies? Has your relative spent any less time engaging in these activities?
If s/he is not as interested, or has not been that engaged in activities during the past week:
Has your relative had to push him/herself to do the things s/he normally enjoys? Has your
relative stopped doing anything s/he used to do? Can s/he look forward to anything or has s/he
lost interest in many of the hobbies from which s/he used to derive pleasure?
Ratings of this item should be based on loss of interest during the past week. This item
should be rated 0 if the loss of interest is long-standing (longer than 1 month) and there has
been no worsening during the past month. This item should be rated 0 if the patient has
not been engaged in activities because of physical illness or disability, or if the patient has
persistent apathy associated with dementia.
C. Physical Signs
9. Appetite loss: (eating less than usual) How has your relative’s appetite been this past week
compared to normal? Has it decreased at all? Has your relative felt less hungry or had to remind
him/herself to eat? Have others had to urge or force him/her to eat?
–– Rate 1 if there is appetite loss but still s/he is eating on his/her own.
–– Rate 2 if eats only with others’ encouragement or urging.
10. Weight loss: Has your relative lost any weight in the past month that s/he has not meant to
or been trying to lose? (If not sure: are your relative’s clothes any looser on him/her?) If weight loss
is associated with present illness (ie, not due to diet or exercise): how many pounds has s/he lost?
–– Rate 2 if weight loss is greater than 5 pounds in past month.
11. Lack of energy: (fatigues easily, unable to sustain activities – score only if change occurred
acutely, or in less than one month) How has your relative’s energy been this past week compared
to normal? Has s/he been tired all the time? Has s/he asked to take naps because of fatigue?
This week, has your relative had any of the following symptoms due to lack of energy only (not
due to physical problems):
•• heaviness in limbs, back, or head?
•• felt like s/he is dragging through the day?
Has your relative been fatigued more easily this week?
–– Ratings of this item should be based on lack of energy during the week prior to the
interview. This item should be rated 0 if the lack of energy is long-standing (longer than 1
month) and there has been no worsening during the past month.
D. Cyclic Functions
12. Diurnal variation of mood: (symptoms worse in the morning) Regarding your relative’s
mood (his/her feelings and symptoms of depression), is there any part of the day in which s/
he usually feels better or worse? (or does it not make any difference, or vary according to
the day or situation?)
–– If yes to a difference in mood during the day: Is your relative’s depression worse in the
morning or the evening?
–– If worse in the morning: Is this a mild or a very noticeable difference?
S/he must consistently feel worse in the mornings (as compared to evenings) for this item to be
rated.
Diurnal variation of mood is only rated for symptoms that are worse in the morning.
Variation of mood in the evening can be related to sun downing in patients with dementia and
should not be rated.
13. Difficulty falling asleep: (later than usual for this individual) Has your relative had any
trouble falling asleep this past week? Does it take him/her longer than usual to fall asleep once
s/he gets into bed (ie, more than 30 min)?
–– Rate 1 if patient only had trouble falling asleep a few nights in the past week.
–– Rate 2 if s/he has had difficulty falling asleep every night this past week.
14. Multiple awakenings during sleep: Has your relative been waking up in the middle of
the night this past week? If yes: does s/he get out of bed? Is this just to go to the bathroom and
then s/he goes back to sleep?
–– Do not rate if waking is only to go to the bathroom and then is able to fall right back asleep.
–– Rate 1 if sleep has only been restless and disturbed occasionally in the past week, and has
not gotten out of bed (besides going to the bathroom).
–– Rate 2 if s/he gets out of bed in the middle of the night (for reasons other than voiding),
and/or has been waking up every night in the past week.
15. Early morning awakenings: (earlier than usual for this individual) Has your relative been
waking up any earlier this week than s/he normally does (without an alarm clock or someone
waking him/her up)? If yes: how much earlier is s/he waking up than is normal for him/her?
Does your relative get out of bed when s/he wakes up early, or does s/he stay in bed and/or go
back to sleep?
–– Rate 1 if s/he wakes up on his/her own but then goes back to sleep.
–– Rate 2 if s/he wakes earlier than usual and then gets out of bed for the day (ie, s/he cannot
fall back asleep).
E. Ideational Disturbance
16. Suicide: (feels life is not worth living, has suicidal wishes, or makes suicide attempt) During the
past week, has your relative had any thoughts that life is not worth living or that s/he would be
better off dead? Has s/he had any thoughts of hurting or even killing him/herself?
–– Rate 1 for passive suicidal ideation (ie, feels life isn’t worth living).
–– Rate 2 for active suicidal wishes, and/or any recent suicide attempts, gestures, or plans.
A ppendix D 71
History of suicide attempt in a subject with no passive or active suicidal ideation does not
in itself justify a score.
17. Self-depreciation: (self-blame, poor self-esteem, feelings of failure) How has your relative
been feeling about him/herself this past week? Has s/he been feeling especially critical of him/
herself, feeling that s/he has done things wrong or let others down? Has s/he been feeling
guilty about anything s/he has or has not done? Has s/he been comparing him/herself to
others, or feeling worthless, or like a failure? Has s/he described him/herself as “no good” or
“inferior”?
–– Rate 1 for loss of self-esteem or self-reproach.
–– Rate 2 for feelings of failure, or statements that s/he is “worthless,” “inferior,” or “no good.”
18. Pessimism: (anticipation of the worst) Has your relative felt pessimistic or discouraged about
his/her future this past week? Can your relative see his/her situation improving? Can your
relative be reassured by others that things will be okay or that his/her situation will improve?
–– Rate 1 if s/he feels pessimistic, but can be reassured by self or others.
–– Rate 2 if feels hopeless and cannot be reassured that his/her future will be okay.
19. Mood congruent delusions: (delusions of poverty, illness, or loss) Has your relative been
having ideas that others may find strange? Does your relative think his/her present illness is
a punishment, or that s/he has brought it on him/herself in some irrational way? Does your
relative think s/he has less money or material possessions than s/he really does?
Interview with the patient

Ratings of most Patient Interview items should be principally based on direct observation.
Questions to the patient may offer supplemental information or be the main reference to how
you have been feeling during the past week.
A. Mood Related Signs:

1. Anxiety: (anxious expression, ruminations, worrying) Does the subject have an anxious, tense,
distressed or apprehensive expression?
Ask the patient: Have you been feeling anxious this past week? Have you been worrying
about things you may not ordinarily worry about, or ruminating over things that may not be
that important?
2. Sadness: (sad expression, sad voice, tearfulness) Does the patient have a sad expression or sad
voice? Is the patient tearful?
Ask the patient: Have you been feeling down, sad, or blue this past week? Have you been
crying at all? How many days out of the past week have you been feeling like this? For how long
each day?
3. Lack of reactivity to pleasant events: Is the patient able to respond to friendly or
supportive remarks or to humor?
Ask the patient: If a pleasant event were to occur today (ie, going out with your spouse,
friends, seeing your grandchildren), would you be able to enjoy it fully, or might your mood get
in the way of your interest in the event or activity? Does your mood affect any of the following:
•• your ability to enjoy activities that used to give you pleasure?
•• your surroundings?
•• your feelings for your family and friends?
4. Irritability: (easily annoyed, short tempered) Observe whether the patient is easily annoyed
and short-tempered during the interview.
Ask the patient: Have you felt short-tempered or easily annoyed this past week? Have you
been feeling irritable, impatient, or angry this week?
B. Behavioral Disturbance
5. Agitation (restlessness, hand-wringing, hair-pulling): Observe the patient for behaviors such as
playing with his/her hands, hair, hand-wringing, hair-pulling, and/or lip-biting.
Ask the patient: Have you been fidgety or restless this past week? Have you been unable to
sit still for at least an hour? Were you so physically agitated to the point that others noticed it?
6. Retardation: (slow movements, slow speech, slow reactions) This item should be scored
exclusively on the basis of the rater’s observations. Retardation is characterized by:
•• slow speech
•• delayed response to questions
•• decreased motor activity and/or reactions
7. Multiple physical complaints: In the past week, have you had any of the following physical
symptoms in excess to what is normal for you:
•• indigestion?
•• constipation?
•• diarrhea?
•• stomach cramps?
•• belching?
•• heart palpitations?
•• headaches?
•• muscle aches?
•• joint pain?
•• backache?
•• hyperventilation (shortness of breath)?
•• frequent urination?
•• sweating?
If yes to any of the above: How much have these things been bothering you? How bad have
they gotten and how often have they occurred in the past week?
–– Do not rate symptoms that are side effects from taking medications or those that are only
related to gastrointestinal ailments.
A ppendix D 73
8. Loss of interest: (less involved in usual activities – score only if change occurred acutely, or in less
than one month) How have you been spending your time this past week (not including work
and chores)? Have you felt interested in what you usually like to do? Have you spent any less
time engaging in these activities?
If not as interested, or has not been engaged in activities during the past week: Have you
had to push yourself to do the things you normally enjoy? Have you stopped doing anything
you used to do? Can you look forward to anything or have you lost interest in many of the
hobbies from which you used to derive pleasure?
Ratings of this item should be based on loss of interest during the past week. This item
should be rated 0 if the loss of interest is long-standing (longer than 1 month) and there has
been no worsening during the past month. This item should be rated 0, if the patient has
not been engaged in activities because of physical illness or disability or if the patient has
persistent apathy as part of his/her dementia.
C. Physical Signs
9. Appetite Loss: (eating less than usual) How has your appetite been this past week compared
to normal? Has it decreased at all? Have you felt less hungry or had to remind yourself to eat?
Have others had to urge or force you to eat?
–– Rate 1 if appetite loss but still eating on his/her own.
–– Rate 2 if eats only with others’ encouragement or urging.
10. Weight Loss: Have you lost any weight in the past month that you have not been trying to
lose? (If not sure: are your clothes any looser on you?) If weight loss is associated with present
illness (ie, not due to diet or exercise): how many pounds have you lost?
–– Rate 2 if weight loss is greater than 5 lbs. in past month.
11. Lack of energy: (fatigues easily, unable to sustain activities – score only if change occurred
acutely, or in less than one month) Does the patient appear fatigued or drained of energy?
Ask the patient: How has your energy been this past week compared to normal? Have you
been tired all the time? Have you needed to take naps because of fatigue? Have you any of the
following symptoms due to lack of energy only (not due to physical problems):
•• heaviness in limbs, back, or head?
•• felt like you are dragging through the day?
–– Ratings of this item should be based on lack of energy during the week prior to the
interview. This item should be rated 0 if the lack of energy is longstanding (longer than 1
month) and there has been no worsening during the past month.
D. Cyclic Functions
12. Diurnal variation of mood: (symptoms worse in the morning) Regarding your mood
(feelings and symptoms of depression), is there any part of the day in which you usually
feel better or worse? (Or does it not make any difference, or vary according to the day or
situation?)
–– If yes to a difference in mood during the day: Is your depression worse in the morning or
the evening?
–– If worse in the morning: is this a mild or a very noticeable difference?
The subject must feel consistently worse in the mornings (as compared to evenings) for this
item to be rated.
Diurnal variation of mood is only rated for symptoms that are worse in the morning.
Variation of mood in the evening can be related to sun downing in patients with dementia and
should not be rated.
13. Difficulty falling asleep: (later than usual for this individual) Have you had any trouble
falling asleep this past week? Does it take you longer than usual to fall asleep once you get into
bed (ie, more than 30 min)?
–– Rate 1 if only the subject had trouble falling asleep a few nights in the past week.
–– Rate 2 if s/he has had difficulty falling asleep every night this past week.
14. Multiple awakenings during sleep: Have you been waking up in the middle of the night
this past week more than usual? If yes: do you get out of bed? Is this just to go to the bathroom
and then you go back to sleep?
–– Do not rate if waking is only to go to the bathroom and then is able to fall right back asleep.
–– Rate 1 if sleep has only been restless and disturbed occasionally in the past week, and has
not gotten out of bed (besides going to the bathroom).
–– Rate 2 if s/he gets out of bed in the middle of the night (for reasons other than voiding),
and/or has been waking up every night in the past week.
15. Early morning awakenings: (earlier than usual for this individual) Have you been waking
up any earlier this week than you normally do (without an alarm clock or someone waking you
up)? If yes: how much earlier are you waking up than is normal for you? Do you get out of bed
when you wake up early, or do you stay in bed and/or go back to sleep?
–– Rate 1 if s/he wakes up on his/her own but then goes back to sleep.
–– Rate 2 if s/he wakes earlier than usual and then gets out of bed for the day (ie, s/he cannot
fall back asleep).
E. Ideational Disturbance
16. Suicide: (feels life is not worth living, has suicidal wishes, or makes suicide attempt) During the
past week, have you had any thoughts that life is not worth living or that you would be better
off dead? Have you had any thoughts of hurting or even killing yourself?
–– Rate 1 for passive suicidal ideation (ie, feels life isn’t worth living).
–– Rate 2 for active suicidal wishes, and/or any recent suicide attempts, gestures, or plans.
History of suicide attempt in a subject with no passive or active suicidal ideation does not
in itself justify a score.
17. Self-depreciation: (self-blame, poor self esteem, feelings of failure) How have you been
feeling about yourself this past week? Have you been feeling especially critical of yourself,
feeling that you have done things wrong or let others down? Have you been feeling guilty
A ppendix D 75
about anything you have or have not done? Have you been comparing yourself to others, or
feeling worthless, or like a failure? Have you felt “no good” or “inferior”?
–– Rate 1 for loss of self-esteem or self-reproach.
–– Rate 2 for feelings of failure, or statements that s/he is “worthless,” “inferior,” or “no good.”
18. Pessimism: (anticipation of the worst) Have you felt pessimistic or discouraged about your
future this past week? How do you think things will work out for yourself? Can you see your
situation improving? Can you be reassured by others that things will be okay or that your
situation will improve?
–– Rate 1 if s/he feels pessimistic, but can be reassured by self or others.
–– Rate 2 if feels hopeless and cannot be reassured that his/her future will be okay.
19. Mood congruent delusions: (delusions of poverty, illness, or loss) Have you been seeing or
hearing things that others do not see or hear? Has your imagination been playing tricks on you
in any way, or have you been having ideas that others may not understand? Do you think that
your present illness is a punishment, or that you have brought it on yourself in some way? Do
you think you have a lot less money or material possessions than others say that you have?
Reproduced with permission from Alexopoulos GA, Abrams RC, Young RC, Shamoian CA.
Cornell scale for depression in dementia. Biol Psych. 1988;23:271-284. ©Elsevier.

Guide To Assessment Scales in Major Depressive Disorder

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Guide To Assessment Scales in Major Depressive Disorder

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George Alexopoulos · Siegfried Kasper

Hans-Jürgen Möller · Carmen Moreno

© Springer International Publishing Switzerland 2014

Printed on acid-free paper

Springer is part of Springer Science+Business Media (www.springer.com)

Project editor: Katrina Dorn

1 Introduction to assessment in depression 1

2 Observer rating scales 7

4 Assessment of pediatric depression 35

5 Assessment scales for geriatric patients 43

Siegfried Kasper, MD is Professor of Psychiatry and Chairman of the Department of Psychiatry

Hans-Jürgen Möller, MD, is Emeritus Professor at the Department of Psychiatry, Ludwig

Limitations of rating scales

Using assessment scales in clinical practice

Use of scales in pediatric depression

Use of scales in elderly depression

9 Mombour W. [Frequency of symptoms in psychiatric illnesses. A comparative investigation with two

General aspects of observer rating scales

Examples of observer rating scales for depression

Featured scale: Hamilton Rating Scale for Depression

How to use the Hamilton Rating Scale for Depression

Number Symptom Score

symptoms on the basis of information obtained during a clinical interview. Additional

Number Symptom Range Score

Quality and characteristics of the Hamilton Rating Scale for Depression

22 ∆ = 2.86±0.56 ∆ = 3.00±0.64 ∆ = 3.48±0.72 ∆ = 4.53±1.31

Agomelatine 25–50 mg Placebo ***P<0.001

Featured scale: Montgomery-Åsberg Depression

How to use the Montgomery-Åsberg Depression Rating Scale

Quality and characteristics of the Montgomery-Åsberg Depression Rating Scale

78 Asberg M, Montgomery SA, Perris C et al. A comprehensive psychopathological rating scale.

General aspects of self-rating scales

Examples of self-rating scales in depression

Zung Self-Rating Depression Scale

Hospital Anxiety and Depression Scale

90-Item Self-Report Symptom Inventory

Paranoid Depression Scale

Adjective Mood Scale

Featured scale: Beck Depression Inventory

How to use the Beck Depression Inventory

Quality and characteristics of the Beck Depression Inventory

11 von Zerssen D. Klinische Selbstbeurteilungs-Skalen (KSbS) aus dem Münchener Psychiatrischen

General aspects of pediatric depression scales

Examples of scales in pediatric depression

Kutcher Adolescent Depression Scale

Reynolds Child/Adolescent Depression Scale

Children’s Depression Rating Scale–Revised

Featured scale: Children’s Depression Inventory

General aspects of depression scales for geriatric patients

Examples of observer rating scales for geriatric patients

The Alzheimer’s Disease Assessment Scale

Depression Signs Scale

Dementia Mood Assessment Scale

Featured scale: Cornell Scale for Depression in Dementia

How to use the Cornell Scale for Depression in Dementia

Quality and characteristics of the Cornell Scale for Depression in Dementia

of interest, physical complaints, psychomotor retardation, sadness);

40 de Medeiros K, Robert P, Gauthier S, et al. The Neuropsychiatric Inventory-Clinician rating scale (NPI-

Hamilton Depression Rating Scale, 21-item version

Hamilton Depression Rating Scale (HAM-D), 21-item version

1. Depressed Mood (sadness, hopeless, helpless, worthless)

Ó Springer International Publishing Switzerland 2014 53

Hamilton Depression Rating Scale (HAM-D), 21-item version (continued)